Head and Neck Trauma
There are a number of possible causes of facial trauma. Sports, accidental falls, motor vehicle accidents, assault and work related accidents account for the majority of maxillofacial injuries. Oral and maxillofacial surgeons (OMS) are highly trained and skilled in the management of facial injuries and are involved in all aspects of treatment from care of the initial injuries through any necessary reconstruction and implant placement. Our hospital provide the full range of care for these injuries from the treatment of dentoalveolar fractures to the care of extensive facial lacerations and facial fractures. This section describes the types of facial injuries that occur along with a description of the indicated treatment for these injuries. Goals in the treatment of facial injuries include rapid bone healing, a return of normal ocular, masticatory, and nasal function, restoration of speech, and an acceptable facial and dental esthetic result.
Facial and Jaw Bone Fractures
Facial injuries include injuries involving the mouth, face and jaw. These range from facial cuts and lacerations to more serious problems, such as broken teeth and facial bones.
Bone fractures can involve the lower or upper jaw, palate, cheekbones and eye sockets. These injuries often occur during automobile accidents, sports or recreational activities, fights or assaults, work-related tasks, projects around the house or accidental falls.
Many patients with facial injuries are first seen in the emergency room and then referred to an oral and maxillofacial surgeon or a plastic surgeon for further treatment.
When making a diagnosis, your doctor will begin by asking about your medical history, including any events that may have caused your facial injury. A thorough physical and medical examination will also be conducted, to note any injuries to your face and other parts of your body. Many people with facial injuries also suffer from additional medical problems.
Treatment for facial injuries varies, depending on the location and severity of your injury. Patients with facial injuries may additional medical problems. Your doctor will coordinate the care of these medical conditions with the necessary specialists.
If you have broken bones in your face, the bones must be lined up and held in place long enough to heal properly. Depending on the severity of the injury and your age, this may take six or more weeks.
Repositioning and holding your broken bones in place may be achieved by a variety of techniques. For extensive facial injuries, incisions to expose the bones and then a combination of wiring and plating techniques may be used. Fractures of the upper and lower jaw may require metal braces that are fastened to your teeth with rubber bands or wires to hold your jaws together.
Orbital and Nasal Bone Fractures
Nose is the most prominent part of the face, hence it is likely to be the most common structure to be injured in the face. Although fractures involving the nasal bones are very common, it is often ignored by the patient. Patients with fractures of nasal bone will have deformity, tenderness, hemorrhage, edema, ecchymosis, instability, and crepitation. These features may be present in varying combinations.
If fractures of nasal bones are left uncorrected it could lead to loss of structural integrity and the soft tissue changes that follow may lead to both unfavorable appearance and function. The management of nasal fractures is based solely on the clinical assessment of function and appearance; therefore, a thorough physical examination of a decongested nose is paramount.
Patients with fractures involving nose will have intense bleeding from nose making assessment a little difficult. Bleeding must first be controlled by nasal packing. These patients also have considerable amount of swelling involving the dorsum of the nose, making assessment difficult. These patients must be conservatively managed for atleast 3 weeks for the oedema to subside to enable precise assessment of bony injury. According to Cummins Fracture reduction should be accomplished when accurate evaluation and manipulation of the mobile nasal bones can be performed; this is usually within 5-10 days in adults and 3-7 days in children.
Oral and Facial Infections
Infections of the jaws and facial bones can come from a variety of sources. The most common cause is abscess of the teeth. Infection follows the path of least resistance, so the location of facial swelling varies, depending on which tooth is infected. Everyone responds differently to having an infection. Some patients are able to contain the infection and keep it under control. In other patients, the infection may spread and cause fever, swelling, sore throat, and a generally ill feeing. It is important to seek consultation whenever an area of pain exists in the mouth, so that serious complications do not develop. Do not ignore the important signs of pain and fever, as they usually signal the presence of a significant infection.
Most infections are treated by antibiotic medications, and most importantly, by removal of the source of the infection. Warm salt water rinses and warm compresses are also helpful to increase blood flow to the area. Serious infections require surgical drainage of the area of abscess, known as an “incision and drainage” procedure.
Usually, an infection of a lower jaw tooth will lead to swelling on the lower jaw. A small infection like this can cause an abscess that can spread down the throat, and go as far as the sac around the heart.
Infections of the upper teeth usually spread to the cheek and the area under the eye. Some of the veins in this area do not have valves, so blood can flow backward and spread infection to an area under the brain, known as the cavernous sinus. Notice the swelling of the lower eyelid in this patient.
This patient had a very severe infection. Notice both the upper and lower eyelids are red and swollen, in addition to the cheek. He required admission to the hospital for many days of intravenous antibiotics. This was caused by a single abscessed tooth. An incision and drainage (I & D) was performed to release the pus and pressure, which was spreading rapidly. A rubber drain was placed into the area to allow for continued drainage of the infection. Drains may be left in place for 1 to 5 days or more, depending on the severity of the infection.
This woman was referred by her dermatologist because of an area on her skin that was continually draining pus. It was originally treated as a superficial skin abscess, but failed to respond to antibiotics. With thorough questioning, she disclosed that she had a cosmetic chin implant placed by a plastic surgeon many years previously. She commented that her chin had become less prominent over the past year.
On examination, she was tender over the right side of her chin. An x-ray of the area showed a cyst-like area on her lower jaw. The chin implant had eroded into her lower jaw, and become infected. The lesion on the skin was a "fistulous tract" from the implant to the skin. She was treated by removal of the chin implant from an incision inside her mouth. Then, from the outside, the fistulous tract and involved skin were excised, the underlying muscles were closed, and the skin was repaired.
Osteomyelities of Jaw and Facial Bones
Osteomyelitis is an infection of the bone. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including:
- An open injury to the bone, such as an open fracture with the bone ends piercing the skin.
- An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis).
- A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.
- Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.
- A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.
Osteomyelitis affects about two out of every 10,000 people. If left untreated, the infection can become chronic and cause a loss of blood supply to the affected bone. When this happens, it can lead to the eventual death of the bone tissue.
Osteomyelitis can affect both adults and children. The bacteria or fungus that can cause osteomyelitis, however, differs among age groups. In adults, osteomyelitis often affects the vertebrae and the pelvis. In children, osteomyelitis usually affects the adjacent ends of long bones. Long bones (bones of the limbs) are large, dense bones that provide strength, structure, and mobility. They include the femur and tibia in the legs and the humerus and radius in the arms.
Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including:
- People with diabetes
- Patients receiving hemodialysis
- People with weakened immune systems
- People with sickle cell disease
- Intravenous drug abusers
- The elderly
Symptoms of osteomyelitis
The symptoms of osteomyelitis can include:
- Pain and/or tenderness in the infected area
- Swelling and warmth in the infected area
- Nausea, secondarily from being ill with infection
- General discomfort, uneasiness, or ill feeling
- Drainage of pus through the skin
Additional symptoms that may be associated with this disease include:
- Excessive sweating
- Lower back pain (if the spine is involved)
- Swelling of the ankles, feet, and legs
- Changes in gait (walking pattern that is a painful, yielding a limp)
To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis:
- Blood tests: When testing the blood, measurements are taken to confirm an infection: a CBC (complete blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body.
- Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment.
- Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media.
- Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism.
- Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when X-ray findings may only show normal findings.
Treating and managing osteomyelitis
The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease as soon as possible.
Drainage: If there is an open wound or abscess, it may be drained through a procedure called needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over often-unreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are drained by open surgical procedures.
Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone. The dosage and type of antibiotic prescribed depends on the type of bacteria present and the extent of infection. While antibiotics are often given intravenously, some are also very effective when given in an oral dosage. It is important to first identify the offending organism through blood cultures, aspiration, and biopsy so that the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to starting antibiotics.
Splinting or cast immobilization: This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children, although motion of joints after initial control is important to prevent stiffness and atrophy.
Surgery: Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteria involved in the infection are then intensively administered during the hospital stay and for many weeks afterward.
With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to treatment that amputation may be required; however, this is rare. Also, over many years, chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the chronic drainage site, should be evaluated by a physician experienced in treating chronic bone infections. Because it is important that osteomyelitis receives prompt medical attention, people who are at a higher risk of developing osteomyelitis should call their doctors as soon as possible if any symptoms arise.
Cyst and Tumour of Head and Neck
Head and neck cancers in childhood are rare, but congenital cysts and infections occur with some regularity. The management of these problems requires special training and ongoing experience in the complex surgical anatomy of a child’s head and neck area.
The Section of Pediatric Otolaryngology at Cleveland Clinic has extensive experience in the care of children with head and neck problems such as craniofacial anomalies, pediatric neck masses(malignant and benign), branchial cleft cysts, thyroglossal duct cysts, lymphovascular malformations, hemangiomas, and parotid tumors.
We provide emergency services for children with acute head and neck infections that need urgent medical and surgical treatment, working closely with our colleagues in pediatric infectious disease in order to achieve rapid resolution of the infection. We also work closely with our pediatric oncologists in rendering state-of-the-art care for those children who require surgical resection of tumors in the head and neck region.
Oral cancer includes cancer of the lips, tongue, cheeks, floor of mouth, hard palate, gums and minor salivary glands. Oral cancer usually occurs in people over the age of 45 but can develop at any age
If an abnormal area has been found in the oral cavity, a biopsy will determine whether it is cancer. Usually, you are referred to a head and neck surgeon, who removes part or all of the lump or abnormal looking area. A pathologist examines the tissue under a microscope to check for cancer cells.
Almost all oral cancers are squamous cell carcinomas, since squamous cells line the oral cavity.
The extent of treatment for oral cancer depends on a number of factors. Among them are the location, size, type and extent of the tumor and stage of the disease. Your doctor also considers your age and general health. Treatment may involve surgery, radiation therapy or a combination. You also may receive chemotherapy, or treatment with anticancer drugs.
For most patients, it is important to have a complete dental exam before cancer treatment begins. Because cancer treatment may make the mouth sensitive and more easily infected, doctors often advise to have dental work done before treatment begins.
SurgerySurgery to remove the tumor in the mouth is the usual treatment for patients with oral cancer. If there is evidence that the cancer has spread or a concern that it has spread, the surgeon may also remove lymph nodes in the neck. If the disease has spread to muscles and other tissues in the neck, the operation may be more extensive.
Radiation TherapyRadiation therapy, also called radiotherapy, is the use of high-energy rays to damage cancer cells and stop them from growing. Like surgery, radiation therapy is local therapy, affecting only the cells in the treated area. The energy may come from a large machine, or external radiation. Patients with large tumors may need both surgery and radiation therapy.
ChemotherapyChemotherapy is the use of drugs to kill cancer cells. Researchers are looking for effective drugs or drug combinations to treat oral cancer. They are also exploring ways to combine chemotherapy with other forms of cancer treatment to help destroy the tumor and prevent the disease from spreading.
The term "malignant" indicates that there is moderate to high probability that the tumor will spread beyond the site where it initially develops. These cells can spread by travel through the blood stream or by travel through lymph vessels. The most common sites where malignant bone tumors spread are the liver and the lungs. Other bones can also become sites of metastasis.
Malignant soft tissue tumors are classified as "sarcomas." These tumors are thought to arise from "connective tissues" other than bone, such as muscle, tendon, ligament, fat, and cartilage. They are rare. Only about 8,000 tumors of this type occur each year in the United States, representing only about 1% of all malignant tumors. They are technically different from the much more common cancers or "carcinomas," which are malignant tumors that arise from organs or gland tissue (e.g. breast, prostate, colon, liver, kidney, lung, thyroid gland, etc). However, all are serious tumors that must be treated with great caution.
Fortunately, in over 90% of patients in whom a malignant tumor is discovered there is no visible evidence that the tumor has spread. However, this does not guarantee that there are not already small areas of spread. This is important because, if the tumor has already spread, the individual cannot be cured by simply removing the visible tumor at the primary site. Pathologists are now able to examine many tumors under the microscope and divide tumors into high-grade tumors, which have a 70-90% chance of having spread, and low-grade tumors, where the chance of spread is low (less than 15%). This allows additional therapy to be specifically targeted to the most dangerous tumors, and allows many of the low-grade tumors to be successfully treated by surgery alone.
Malignant soft tissue tumors can occur at almost any age, but are most common in individuals between 50 and 70 years of age. Malignant fibrous histiocytoma (MFH), liposarcoma, and synovial sarcoma, neurosarcoma, rhabdosarcoma, fibrosarcoma, hemangiopericytoma, and angiosarcoma are among the most common of these tumors, but many other types exist.
What are the symptoms?
In its early stages, soft tissue malignant tumors rarely cause any symptoms. Because soft tissue is very elastic, the tumors can grow quite large before they are felt. The first symptom is usually a painless lump. As the tumor grows and begins to press against nearby nerves and muscles, pain or soreness can occur.
Any growing tumor should be recognized and evaluated promptly.
What are my treatment options?
Optimal treatment often demands the combined skills of an exceptional surgeon, pathologist, radiologist, radiotherapist, medical oncologist, and sometimes a plastic surgeon.
In the past 15 years, important improvements have been made in the treatment of malignant soft tissue tumors.
The addition of chemotherapy for the highest-grade tumors reduces the rate at which high-grade tumors return and may improve the rate of cure. The use of specialized radiation therapy techniques has significantly reduced the likelihood of tumors coming back at the site where they have been removed. Often, depending on the type of tumor, preoperative radiation therapy or chemotherapy (or a combination of the two) may be used to make some of these tumors more easily resected with adequate margins.
Radiation therapy, in combination with improved techniques for surgical removal and improved methods for functional reconstruction, now allows 90-95% of patients with these aggressive tumors to be treated using "limb salvage" (Create link to limb salvage section) techniques (i.e. without amputation).
What are the risks of surgery?
Risks include nerve injury, infection, bleeding, and stiffness.
How do I prepare for surgery?
- Complete any pre-operative tests or lab work prescribed by your doctor.
- Arrange to have someone drive you home from the hospital.
- Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs) one week prior to surgery.
- Call the appropriate surgery center to verify your appointment time.
- If your surgery is being done at Cleveland Clinic, call 216.444.0281.
- Refrain from eating or drinking anything after midnight the night before surgery.
Are there exercises I can start now prior to surgery?
Patients with lower extremity procedures most likely will require crutches. Physical therapy, including crutch instruction, is easier to accomplish before the surgery.
What do I need to do the day of surgery?
- If you currently take any medications, take them the day of your surgery with just a sip of water.
- Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
- Leave valuables and money at home.
- Wear loose-fitting, comfortable clothing.
What happens after surgery?
Post-operative instructions will be provided.
How long is the recovery period after surgery?
The recovery period depends upon the bone lesion and location. Wound healing takes about two weeks. If bone healing is necessary, the physician may require patients to protect the extremity for six weeks from major forces such as full weight-bearing.
What is the rehab after surgery?
Depending on the procedure, physical therapy for crutch use, range-of-motion and strengthening may be required.
How can I manage at home during recovery from the procedure?
Instructions from the physician will be provided. These will vary according to the procedure.
What is TMJ Ankylosis?Ankylosis is the stiffening (immobility) or fixation (fusion) of the joint. Chronic, painless limitation of the movements of the joint occurs.
Intra-articular (true) ankylosis must be distinguished from extra-articular (false) ankylosis. False ankylosis may be caused by enlargement of the coronoid process, depressed fracture of the zygomatic arch, scarring from surgery, irradiation, infection, etc.
True ankylosis of the mandible is one of the most disturbing articular pathosis of TMJ, causing many psychological and physical disturbances. When the pathosis affects both the joints it completely inhibits the movements of the mandible, making chewing, swallowing and speech very difficult. The facial development is impaired resulting in retarded growth of the mandible. Since the condyle of the mandible is the growth center (area of bone growth) for the mandible, any disturbance in this region provokes a change in the development of the mandible. True bilateral congenital ankylosis of the TMJ leads to micrognathia or “bird face”. If ankylosis affects only one side, it produces a lateral deviation of the jaw to the non-affected side, due to the fact that this side continues its growth normally. Therefore the deformity becomes more evident on the normal side, with deficiency on the ankylosed side, causing a facial asymmetry.
What are the causes of TMJ Ankylosis?
- Trauma to the joint during an accident, fall etc
- Trauma during birth, forceps delivery etc
- Congenital or birth defect
- Disease or infection in the joint, ear infection etc
- Enlargement of the coronoid process
- Depressed fracture of the zygomatic arch, condylar neck fracture etc
- Surgery to or around the joint
- Rheumatoid arthritis
- Ankylotic conditions such as ankylosing spondylitis may also be inherited.
- Destruction of the joint cartilage
What are the problems associated with TMJ Ankylosis?Problems associated with ankylosis of TMJ are manifold and can be Functional, Aesthetic (Cosmetic), Psychological (Emotional) or Social.
Ankylosis of Temporomandibular joint may result in:
- Restricted jaw movements
- Inadequate masticatory (chewing) function
- Restricted mouth opening
- Inhibited facial and physical growth
- Impaired speech
- Reduced growth of mandible resulting in “Bird Face”
- Facial asymmetry if only one side is affected
- Difficulty in breathing and swallowing
- Snoring and difficulty in sleeping on lying down
- Insufficient access for dental care resulting in multiple decayed teeth
- Misaligned teeth because of lack of space for the eruption of the normal component of teeth
- Other emotional, social and psychological disturbances.
What are the treatments for TMJ ankylosis?Over the past few decades numerous treatment methods have been designed and developed by various surgeons for the correction of TMJ ankylosis.
- Excision of ankylosis (gap arthroplasty)
- Arthroplasty with or without autogenous, alloplastic or allogenic replacement
- Condylectomy if the ankylosis is intra-articular or an osteotomy of a part of the ramus if the coronoid process and zygomatic arch are also affected.
- Total condylectomy and joint replacement (autogenous, allogenic, alloplastic)
- Coronoidectomy or coronoidotomy: This is the excision of the coronoid process of the mandible to release the temporalis muscle.
Temporomandibular disorders (TMD) are disorders that develop from problems with the fit between the upper and lower teeth, the jaw joint, and the muscles in the face that control chewing and moving the jaw.
What is the temporomandibular joint?
The temporomandibular joint (TMJ) is the jaw joint. It is the hinge joint that connects the lower jaw (mandible) to the temporal bone of the skull, which is immediately in front of the ear on each side of your head. The joints move smoothly up and down and side to side, which allows you to talk, chew, and yawn. Muscles attached to and surrounding the jaw joint control its position and how it moves.
What causes TMD
TMD can be caused by injury to the jaw, TMJ, or muscles of the head and neck, such as from a heavy blow. Other causes include:
- Grinding or clenching the teeth (puts a lot of pressure on the TMJ)
- Dislocation of the soft cushion or disc between the ball and socket
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
- Stress, which can cause a person to tighten muscles in the face and jaw or to clench the teeth
What are the symptoms of TMD?
People with TMD can feel severe pain and discomfort that can be temporary or last for many years. TMD is most common in those 20 to 40 years of age and is more common in women than in men.
Symptoms of TMD include:
- Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when you chew, speak, or open your mouth wide
- Limited ability to open the mouth very wide
- Jaws that get “stuck” or “lock” in the open- or closed-mouth position
- Clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth. Pain may also be present.
- A tired feeling in the face
- Difficulty chewing or a sudden uncomfortable bite – as if the upper and lower teeth are not fitting together properly
- Swelling on the side of the face
Other common symptoms include toothaches, headaches, neck aches, dizziness, and earaches and hearing problems.
How is TMD diagnosed?
Because other conditions cause similar symptoms -- including a toothache, sinus problems, arthritis, or gum disease -- a thorough history and clinical exam is taken. Temporomandibular joints are examined for pain or tenderness; clicking, popping, or grating sounds during jaw movement; limited motion or locking of the jaw while opening or closing the mouth; and bite and facial muscle function.
Panoramic x-rays might be taken. These full face x-rays show the entire jaws, TMJ, and teeth to make sure other problems aren’t causing the symptoms. Sometimes other imaging tests are needed. Magnetic resonance imaging (MRI) views the soft tissue, such as the TMJ disc, to see if it is in the proper position as the jaw moves. A computed tomography CT scan helps view the bony detail of the joint.
You may be seen by a maxillofacial surgeon for further care and treatment. This doctor specializes in surgical procedures in and about the entire face, mouth, and jaw area.
Pain in the facial area may be due to neurological or vascular causes, but equally well may be dental in origin. The patient will often make the first attempt at diagnosis in that he or she chooses to consult either the dentist or the doctor. This may therefore lead to inappropriate diagnosis and treatment. Many patients with trigeminal neuralgia complain that their dentist treated them for dental causes of pain before finally they received the correct diagnosis. This is, however, highly understandable as dental pain is extremely common whereas trigeminal neuralgia is a rare condition and primary care medical and dental practitioners may only see three or four cases in their practising lifetime. All the neurological and vascular causes of facial pain (excluding headaches) are rare compared to the dental and temporomandibular causes. The risk factors for some of the conditions are known, but there is little information on natural history and prognosis. Further details of the epidemiology of facial pain can be found in Epidemiology of pain, which has been written using evidence based methodology.
In many respects treatment of a patient with chronic facial pain is no different from treating any patient with chronic pain, as the psychosocial and behavioural response patterns are the same despite different medical and dental causes. However, you need to remember that the psychological and symbolic significance of the head in the development of self esteem, body image, and interpersonal relationships confers special meaning on pain in this area.
Time needs to be spent in educating the patient and coming to a negotiated treatment plan that places the patient in the centre. This process involves active patient participation, good communication skills, appropriate choice of treatment based on high quality evidence, increased patient information, and self support as well as an emphatic clinician. Chronic facial pain cannot always be totally abolished and so it is important to have in place long term strategies for its management. Regular reassessment is vital and may even include a possible change in diagnosis.
Orthognathic surgery involves a wide variety of surgical procedures performed to place the teeth, jaw bones, and other associated hard and soft tissue structures into their best anatomical positions. This may be necessary as a result of congenital abnormalities, growth disturbances or trauma. Correction of these abnormalities generally results in improvement in function such as chewing, speaking and breathing and often enhances facial esthetics.
Whenever a jaw and bite abnormality is severe enough that orthodontics alone cannot correct the problem, surgery is often necessary. In this type of case the orthodontist moves the upper teeth into their best position in relation to the upper jaw and the lower teeth into the best position in relation to the lower jaw. Surgery is then necessary to correct the position of either the upper jaw, lower jaw or both. After the jaws are repositioned, the orthodontist is then able to properly finish the bite into the best possible relationship. Surgery may also be helpful as an adjunct to orthodontic treatment to enhance the long term results of orthodontic treatment, and to shorten the overall time necessary to complete treatment.
Distraction osteogenesis (DO) is a relatively new method of treatment for selected deformities and defects of the oral and facial skeleton. It was first used in 1903. Then, in the 1950's, a Russian orthopedic surgeon, Dr. Gabriel Llizarov slowly perfected the surgical and postoperative management of distraction osteogenesis treatment to correct deformities and repair defects of the arms and legs. His work went largely unnoticed until it was presented to the Western Medical Society in the mid-1960's.
Distraction osteogenesis was initially used to treat defects of the oral and facial region in 1990. Since then, the surgical and technological advances made in the field of distraction osteogenesis have provided oral and maxillofacial surgeons with a safe and predictable method to treat selected deformities of the oral and facial skeleton.
The doctors use distraction osteogenesis to treat selected deformities and defects of the oral and facial skeleton. If you have questions about distraction osteogenesis, please contact our office to schedule an appointment for further discussion.
Frequently Asked Questions About Distraction Osteogenesis:
- What does the term distraction osteogenesis mean? Simply stated, distraction osteogenesis means the slow movement apart (distraction) of two bony segments in a manner such that new bone is allowed to fill in the gap created by the separating bony segments.
- Is the surgery for distraction osteogenesis more involved than "traditional surgery" for a similar procedure? Not usually, Distraction osteogenesis surgery is commomly performed on an outpatient basis with most of the patients going home the same day of surgery. The surgical procedure itself is less invasive so there is usually less pain and swelling.
- Will my insurance company cover the cost of osteogenesis surgical procedure? Most insurance companies will cover the cost of the osteogenesis surgical procedure provided that there is adequate and accurate documentation of the patient's condition. Of course, individual benefits within any insurance companies policy may vary. After you are examined for your consultation, we will be able to assist you in determining whether or not your insurance company will cover a particular surgical procedure.
- Is distraction osteogenesis painful? Since all distraction osteogenesis surgical procedures are performed while the patient is under general anesthesia, pain during the surgical procedure is not an issue. Postoperatively, you will be supplied with appropriate analgesics (pain killers) to keep you comfortable, and antibiotics to fight off infection. Activation of the distraction device to slowly separate the bones may cause some patients mild discomfort. In general, the slow movement of bony segments produces discomfort that is analogous to having orthodontic braces tightened.
- What are the benefits of distraction osteogenesis versus traditional surgery for a similar condition? Distraction osteogenesis typically produces less pain and swelling than the traditional surgical procedure for a similar condition. Distraction osteogenesis eliminates the need for bone grafts, and therefore, another surgical site. Lastly, distraction osteogenesis is associated with greater stability when used in major cases where significant movement of bony segments is involved.
- What are the disadvantages of distraction osteogenesis? Distraction osteogenesis requires the patient to return to the surgeon's office frequently during the initial two weeks after surgery. This is necessary because in this time frame the surgeon will need to closely monitor the patient for any infection and teach the patient how to activate the appliance.
- Does distraction osteogensis involve additional surgery? In some cases, a second minor surgical procedure is necessary to remove the distraction appliance.
- Can distraction osteogenesis be used instead of bone grafts to add bone to my jaws? Yes. Recent advances in technology have provided the oral and maxillofacial surgeon with a distraction device that can be used to slowly grow bone in selected areas of bone loss that has occurred in the upper and lower jaws. The newly formed bone can then serve as an excellent foundation for dental implants.
- Does distraction osteogenesis leave scars on the face? No. The entire surgery is done within the mouth and the distraction devices used by the doctors remain inside the mouth. There are no facial surgical incisions, so no unsightly facial scars will result.
- Are there any age limitations for patients who can receive osteogenesis?
No. Distraction osteogenesis works well on patients of all ages. In
general, the younger the patient the shorter the distraction time and
the faster the consolidation phase. Adults require slightly longer
period of distraction and consolidation because the bone regenerative
capabilities are slightly slower than those of adolescence or infants.
Cleft Lip and Palate
Cleft lip and cleft palate malformations arise when the developing face fails to fuse early in pregnancy. Cleft lip with or without cleft palate is one of the most common congenital abnormalities. The formation of the fetal face occurs in the first trimester of pregnancy. Cleft lip is a defect of normal continuity of the upper lip and jaw and can be complete or incomplete depending on severity and structures involved. In addition to the obvious external deformity, a multitude of functional problems exist including difficulty feeding, communication between the mouth and nose, and normal speech development.
A cleft palate involves a separation in the roof of the mouth. The defect may encompass both the hard (bone) and soft palate. The mobile soft palate is responsible for controlling airflow in the formation of speech. The escape of air through the palatal incompetence creates a nasal sound.
The incidence of cleft lip is approximately 1 in 1000 births. The incidence varies according to race with American Indians the highest of any known group and the black population possessing the lowest rate. Cleft palate occurs in roughly 1 in 2000 births and females are affected twice as often as males. In contrast, cleft lip occurs more frequently in males and is most often isolated on the left side. The incidence of clefting is increased from falling birth mortality, increasing maternal age, increasing therapeutic drug consumption and increasing associated abnormalities.
The cause of cleft lip and palate is generally regarded as multifactorial with both genetic and environmental influence. An increased chance of clefting exists in a newborn if a sibling, parent or relative has a cleft (2% to 5% with one affected family member verses 0.14% normally). Environmental factors are associated with influences on the fetus during pregnancy including medications, alcohol and tobacco. Cleft lip with or without cleft palate can be isolated or associated with other congential abnormalities.
The team of our hospital, consisting of a plastic surgeon, genetics specialist, speech pathologist, pediatric dentists, orthodontist, oral surgeons and otolaryngologists, has been treating the complex functional and cosmetic aspects associated with cleft lip and palate for nearly thirty years. Biweekly meetings are held to monitor facial growth and development as individuals’ transition through speech development and eruption of teeth.
Neonatal care focuses on parental counseling and nursing education as the absence of suckling makes feeding challenging. Hearing is also closely monitored as most children affected with cleft lip and palate have inner ear abnormalities.
Surgery is required at multiple stages for repair of the cleft lip and/or palate. The timing of surgical intervention is based on balancing growth and function. Early surgery can create scarring and slow growth. The ideal is to delay surgery to allow for normal growth until function is necessary.
Closure of the lip (cheilorrhaphy) is generally completed at 3 months of age. The goal is to restore continuity of the upper lip skin and muscle for function. The development of speech dictates the surgical repair of the cleft palate typically at 16 to 24 months of age. Additional surgery may be required on the roof of the mouth to help improve the mobility of the soft palate during speech and limit the escape of air into the nose creating nasal speech (staphylorrhaphy). Restoring the continuity of the tooth bearing upper jaw is accomplished at 8 to 11 years. The timing is based on the development and eruption of permanent teeth adjacent to the cleft. Teeth typically found in this region of the jaw are often absent in clefts. Closure of the commnication between the mouth and nose is also an important goal in correction of the bony cleft. Orthodontic guidance is used throughout the transitioning into the permanent teeth to aid in the orientation.
Multiple surgeries involving the lip, roof of the mouth and jaw restricts growth of the upper jaw creating deficiency in the midface. Surgery to advance the upper jaw is completed in the teenage years to correct the bite. Additional surgical revisions may be required on the lip, nose, etc. to finalize cosmetics and function
An impacted tooth simply means that it is “stuck” and can not erupt into function. Patients frequently develop problems with impacted third molar (wisdom) teeth. These teeth get “stuck” in the back of the jaw and can develop painful infections among a host of other problems (see “Impacted wisdom teeth” under Procedures). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspid (upper eye tooth) is the second most common tooth to become impacted. The cuspid tooth is a critical tooth in the dental arch and plays an important role in your “bite”. The cuspid teeth are very strong biting teeth which have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together so they guide the rest of the teeth into the proper bite.
Normally, the maxillary cuspid teeth are the last of the “front” teeth to erupt into place. They usually come into place around age 13 and cause any space left between the upper front teeth to close tight together. If a cuspid tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch. The techniques involved to aid eruption can be applied to any impacted tooth in the upper or lower jaw, but most commonly they are applied to the maxillary cuspid (upper eye) teeth. 60% of these impacted eye teeth are located on the palatal (roof of the mouth) side of the dental arch. The remaining impacted eye teeth are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.
The older the patient, the more likely an impacted eye tooth will not erupt by nature’s forces alone even if the space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends that a panorex screening x-ray along with a dental examination be performed on all dental patients at around the age of 7 years to count the teeth and determine if there are problems with eruption of the adult teeth. It is important to determine whether all the adult teeth are present or are some adult teeth missing. Are there extra teeth present or unusual growths that are blocking the eruption of the eye tooth? Is there extreme crowding or too little space available causing an eruption problem with the eye tooth? This exam is usually performed by your general dentist or hygienist who will refer you to an orthodontist if a problem is identified. Treating such a problem may involve an orthodontist placing braces to open spaces to allow for proper eruption of the adult teeth. Treatment may also require a referral to an oral surgeon for extraction of over retained baby teeth and/or selected adult teeth that are blocking the eruption of the all important eye teeth. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any of the adult teeth. If the eruption path is cleared and the space is opened up by age 11 or 12, there is a good chance the impacted eye tooth will erupt with nature’s help alone. If the eye tooth is allowed to develop too much (age 13-14), the impacted eye tooth will not erupt by itself even with the space cleared for its eruption. If the patient is too old (over 40), there is a much higher chance the tooth will be fused in position. In these cases the tooth will not budge despite all the efforts of the orthodontist and oral surgeon to erupt it into place. Sadly, the only option at this point is to extract the impacted tooth and consider an alternate treatment to replace it in the dental arch (crown on a dental implant or a fixed bridge).
In cases where the eye teeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these unerupted eye teeth to erupt. Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral surgeon. The most common scenario will call for the orthodontist to place braces on the teeth (at least the upper arch). A space will be opened to provide room for the impacted tooth to be moved into its proper position in the dental arch. If the baby eye tooth has not fallen out already, it is usually left in place until the space for the adult eye tooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eye tooth exposed and bracketed.
In a simple surgical procedure performed in the surgeon’s office, the gum on top of the impacted tooth will be lifted up to expose the hidden tooth underneath. If there is a baby tooth present, it will be removed at the same time. Once the tooth is exposed, the oral surgeon will bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature gold chain attached to it. The oral surgeon will guide the chain back to the orthodontic arch wire where it will be temporarily attached. Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth (on selected cases located on the roof of the mouth). Most of the time, the gum will be returned to its original location and sutured back with only the chain remaining visible as it exits a small hole in the gum.
Shortly after surgery (1-14 days) the patient will return to the orthodontist. A rubber band will be attached to the chain to put a light eruptive pulling force on the impacted tooth. This will begin the process of moving the tooth into its proper place in the dental arch. This is a carefully controlled, slow process that may take up to a full year to complete. Remember, the goal is to erupt the impacted tooth and not to extract it! Once the tooth is moved into the arch in its final position, the gum around it will be evaluated to make sure it is sufficiently strong and healthy to last for a lifetime of chewing and tooth brushing. In some circumstances, especially those where the tooth had to be moved a long distance, there may be some minor “gum surgery” required to add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.
Oral Sub Mucous Fibrosis
Oral submucous fibrosis (OSF) is a chronic, complex, irreversible, highly potent pre-cancerous condition characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the submucosal tissues (lamina propria and deeper connective tissues). As the disease progresses, the jaws become rigid to the point that the sufferer is unable to open his mouth. The condition is linked to oral cancers and is associated with areca nut chewing, the main component of betel quid. Areca nut or betel quid chewing, a habit similar to tobacco chewing, is practiced predominantly in Southeast Asia and India, dating back thousands of years.
The treatment of patients with oral submucous fibrosis depends on the degree of clinical involvement. If the disease is detected at a very early stage, cessation of the habit is sufficient. Most patients with oral submucous fibrosis present with moderate-to-severe disease. Moderate-to-severe oral submucous fibrosis is irreversible. Medical treatment is symptomatic and predominantly aimed at improving mouth movements. Treatment strategies include the following:
Steroids: In patients with moderate oral submucous fibrosis, weekly submucosal intralesional injections or topical application of steroids may help prevent further damage.
Placental extracts: The rationale for using placental extract in patients with oral submucous fibrosis derives from its proposed anti-inflammatory effect,hence, preventing or inhibiting mucosal damage. Cessation of areca nut chewing and submucosal administration of aqueous extract of healthy human placental extract (Placentrex) has shown marked improvement of the condition.
Hyaluronidase: The use of topical hyaluronidase has been shown to improve symptoms more quickly than steroids alone. Hyaluronidase can also be added to intralesional steroid preparations. The combination of steroids and topical hyaluronidase shows better long-term results than either agent used alone.
IFN-gamma: This plays a role in the treatment of patients with oral submucous fibrosis because of its immunoregulatory effect. IFN-gamma is a known antifibrotic cytokine. IFN-gamma, through its effect of altering collagen synthesis, appears to be a key factor to the treatment of patients with oral submucous fibrosis, and intralesional injections of the cytokine may have a significant therapeutic effect on oral submucous fibrosis.
Lycopene: Newer studies highlight the benefit of this oral nutritional supplement at a daily dose of 16 mg. Mouth opening in 2 treatment arms (40 patients total) was statistically improved in patients with oral submucous fibrosis. This effect was slightly enhanced with the injection of intralesional betamethasone (two 1-mL ampules of 4 mg each) twice weekly, but the onset of effect was slightly delayed.
Pentoxifylline: In a pilot study, 14 test subjects with advanced oral submucous fibrosis given pentoxifylline at 400 mg 3 times daily were compared to 15 age- and sex-matched diseased control subjects. Statistical improvement was noted in all measures of objective (mouth opening, tongue protrusion, and relief from fibrotic bands) and subjective (intolerance to spices, burning sensation of mouth, tinnitus, difficulty in swallowing, and difficulty in speech) symptoms over a 7-month period. Further studies are needed, but this could be used in conjunction with other therapies.
Facial Nerve Palsy
Facial paralysis occurs when a person is no longer able to move some or all of the muscles of the face. These muscles are responsible for vital functions such as eating, speaking, closing the eyes and expressing emotions.
Facial paralysis may be caused by stroke, trauma, tumors that press on the facial nerve, diseases that affect the facial muscles or infections that may cause temporary or permanent nerve dysfunction.
Doctors at our hospital treat facial paralysis by transferring muscles and repairing blood vessels and nerves.
The diagnosis of facial paralysis is often complicated. Facial paralysis may result from a disruption in the part of the brain called the motor cortex, injury to the facial nerve or damage to the muscles that control facial expression.
Diagnosis involves a consultation with a doctor, a complete physical exam and imaging studies of the brain and face.
Treatment of facial paralysis depends on many factors, including the patient's age, cause of the paralysis, severity of paralysis and duration of symptoms. Symmetry of facial features usually can be regained, if the patient participates in facial muscle retraining and therapy. Both are critical for success.
Doctors at our hospital treat facial paralysis by transferring muscles and repairing blood vessels and nerves. The treatment is determined after the assessment of symptoms and is tailored to each patient's needs.
Disorders of salivary Glands
Your salivary glands make as much as a quart of saliva each day. Saliva is important to lubricate your mouth, help with swallowing, protect your against bacteria, and aid in the digestion of food. The three major pairs of salivary glands are:
- parotid glands on the insides of the cheeks
- submandibular glands at the floor of the mouth
- sublingual glands under the tongue
There are also several hundred minor salivary glands throughout the mouth and throat. Saliva drains into the mouth through small tubes called ducts.
Causes of Salivary Gland ProblemsMany different problems can interfere with the function of the salivary glands or block the ducts so they can't drain saliva. The following are some of the more common salivary gland problems:
Salivary stones, or sialoliths. The most common cause of swollen salivary glands, salivary stones are buildups of crystallized saliva deposits. Sometimes salivary stones can block the flow of saliva. When saliva can't exit through the ducts, it backs up into the gland, causing pain and swelling. Pain is usually off and on, is felt in one gland, and gets progressively worse. Unless the blockage is cleared, the gland is likely to become infected.
Salivary gland infection, or sialadenitis. Bacterial infection of the salivary gland, most commonly the parotid gland, may result when the duct into the mouth is blocked. Sialadenitis creates a painful lump in the gland, and foul-tasting pus drains into the mouth.
Sialadenitis is more common in older adults with salivary stones, but it can also happen in babies during the first few weeks after birth. If not treated, salivary gland infections can cause severe pain, high fevers, and abscess (pus collection).
Infections. Viral infections such as flu, and others can cause swelling of the salivary glands. Swelling happens in parotid glands on both sides of the face, giving the appearance of "chipmunk cheeks."
Salivary gland swelling is commonly associated with mumps, happening in about 30% to 40% of mumps infections. It usually begins approximately 48 hours after the start of other symptoms such as fever and headache.
Other viral illnesses that cause salivary gland swelling include the Epstein-Barr virus (EBV), cytomegalovirus (CMV), Coxsackievirus, and the human immunodeficiency virus (HIV).
Bacterial infections generally cause one-sided salivary gland swelling. Other symptoms such as fever and pain will accompany the swelling. The bacteria are typically those found normally in the mouth, as well as staph bacteria. These infections most often affect the parotid gland. Dehydration and malnutrition raise the risk of getting a bacterial infection.
Cysts. Cysts can develop in the salivary glands if injuries, infections, tumors, or salivary stones block the flow of saliva.Some babies are born with cysts in the parotid gland due to a problem with the development of the ears. It can appear as a blister or soft, raised area. Cysts may interfere with eating and speaking.
Facial Reconstructive Surgery
Reconstructive surgery refers to a variety of operations performed in order to repair or restore parts of the jaws and/or face to look normal, or look better. These types of surgeries are highly specialized. They are characterized by careful preparation of the patient's skin and tissues, by precise cutting and suturing techniques, and by care taken to minimize scarring. Recent advances in the development of miniaturized instruments, new materials for growing and developing bone, and improved surgical techniques have expanded the range of reconstructive surgery operations that can be performed. Because the face is the most inconspicuous part of the human body, it should come as no surprise that those suffering with these defects look for ways to alleviate their facial deformities.
Reconstructive surgery is often performed on accident, cancer/tumor, trauma and burn victims. It may involve the rebuilding of severely fractured bones, bone grafting, flaps of skin and/or muscle as well as skin grafting. Reconstructive surgery includes such procedures as taking tissue from other parts of the body and transplanting them to the mouth or face or implanting a prosthesis. Prostheses are artificial structures and materials that are used to replace missing bone, skin or teeth.
Nobody knows what the exact causes of lichen planus are. We know it can be triggered by taking certain medications, including thiazide diuretics, antimalarials and phenothiazines (a group of tranquilizing drugs with antipsychotic actions). A significant number of skin specialist doctors (dermatologists) believe it might be classified as an autoimmune disease. A higher-than-normal percentage of people with hepatitis C and some other liver diseases have lichen planus.
According to the National Institutes of Health (NIH), USA, lichen planus affects between 1% and 2% of the American population. According to the National Health Service (NHS), UK, around 1 in every 50 people is affected by lichen planus.
Oral lichen planus is more common in women than in men. Skin lichen planus affects both sexes equally. It typically occurs in people over 30 years of age. About half of all affected people have oral lichen planus (symptoms in the inner surface of the mouth). Oral lichen planus typically occurs inside the cheeks, but may also affect the lips, gums and tongue.
Lichen planus symptoms on the skin can take up to two years to go away. However, once gone they hardly ever return. Oral lichen planus can take much longer to go away.
- Does not appear to be an hereditary condition - you cannot pass it on to your children
- Is not an infectious condition - you cannot catch it from somebody with the condition
- Is not a form of cancer
- Occurrence does not seem to be linked to nutrition. However, spicy foods, citrus juices, and tomato products may aggravate symptoms if there are open sores in the mouth.
What are the signs and symptoms of lichen planus?A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign. Lichen planus of the skin:
- The rash appears abruptly, and usually lasts for several months
- There are clumps or patterns of shiny, raised, red/pink/purple, flat-topped papules (bumps)
- Papules are approximately 3mm to 5mm in diameter
- Sometimes there may be white streaks on the papules, called Wickham's striae
- Intense itching, especially at night
- Most affected areas are the wrists, elbows, ankles, and lower back. However, other parts of the body may be affected. The shins may be affected by hypertrophic (thickened) lichen planus, while the armpits may have annular (ring-shaped) lichen planus.
Oral lichen planus (affects the mouth):
- White streaks on the inside of the cheeks. The gums, tongue and lips may also be affected.
- The streaks are not usually painful or itchy
- The white streaks are persistent (they do not go away)
- Possible redness and blistering of the gums
- Sore mouth ulcers can develop, and recur (erosive lichen planus)
- The patient's sense of taste may become blunted. Some experience a metallic taste
- Dry mouth
- Spicy foods, crispy foods, and tomato products can exacerbate symptoms
- Purple/white ring-shaped patches appear around the glans (head of the penis)
- They are not usually itchy
- Symptoms are similar to thrush, and often mistaken for thrush
- Vulva - white streaks develop, similar to those that appear in the mouth. They are usually not itchy or painful. The skin may be red. Erosive lichen planus may affect the inner lips (labia minora) and the entrance to the vagina (introitus) - the affected mucous membrane is bright red and raw. The labia minora may shrink and stick to each other or to the labia majora (outer lips).
- Vagina - may be red. Scar tissue may distort the shape of the vagina. Lichen planus may affect deeper within the vagina, causing desquamative vaginitis. A mucky discharge appears when the surface cells in the vagina peel off. The eroded vagina may easily bleed when touched. Sexual intercourse may become difficult or impossible.
Other areas - lichen planus of the anus, ear canal, eyelids and esophagus (all extremely rare).
(Erosive lichen planus is a chronic, painful condition which affects mucous membranes - mainly the mouth and the genitals.)
What are the risk factors for lichen planus?A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.
Lichen planus can affect humans of any age or race. However, it is more common among:
- Middle-aged adults
- Females (oral lichen planus)
- Patients with liver diseases, such as hepatitis C or cirrhosis
What are the causes of lichen planus?Experts are not sure what the exact causes of lichen planus are. Many believe it is linked to an immune system disorder, where the person's white blood cells - which defend us from bad bacteria, viruses and other germs - mistakenly attack healthy tissues of the skin, mucous membranes, and hair.
Medications - sometimes lichen planus may occur as a reaction to some medicines, such as:
- Beta blockers medications that relieve stress on the heart, slow the heart beat, lessen the force of heart muscle contractions, and reduce blood vessel contraction in the heart, brain, and throughout the body.
- Anti-inflammatory medications
- Gold injections - for the treatment of arthritis
- Thiazide diuretics
- Phenothiazines (a group of tranquilizing drugs with antipsychotic actions)
Mercury tooth fillings - some studies have found a link between lichen planus type changes in the mouth as a result of allergy to mercury tooth fillings. Signs and symptoms go away after the fillings are replaced with non-mercury ones.
Lichen planus can be part of Grinspan's syndrome - a syndrome characterized by hypertension, diabetes and oral lichen planus.
Diagnosing lichen planusAfter examining the skin and identifying the characteristic rash, a GP (general practitioner, primary care physician) may be able to diagnose lichen planus.
Punch biopsy - the doctor uses a circular tool to extract a small sample of the skin's deeper layers. Often stitches are required to close the wound. The sample is examined under a microscope to confirm a lichen planus diagnosis.
If the GP is still unsure, the patient may be referred to a doctor who specializes in skin conditions (a dermatologist).
Oral lichen planus - a dentist or oral specialist usually diagnoses oral lichen planus by taking a biopsy.
What are the treatment options for lichen planus?Lichen planus is not a curable condition. However, when it affects the skin it usually clears within several months (sometimes this may take up to two years). Treatment focuses on easing symptoms until the rash clears. Other types of lichen planus may last much longer.
Mild cases require no treatment by the doctor, except for periodic observations.
Treatment for more severe cases may include:
- Antihistamines - usually taken at night to reduce itching.
- Phototherapy with ultraviolet light
- Topical medications (applied onto the skin):
- Steroid creams or ointments - these can be very effective in reducing inflammation and redness. The medication is applied to the itchy spots. When the spots change color to brown or gray treatment should stop.
- Immunosuppressants - sometimes creams or ointments may contain a steroid-sparing immune-modulating medication (drugs to reduce the immune system).
- Oral corticosteroids (steroid tablets) - for more severe cases, or when creams and ointments are not effective enough.
- Ciclosporin capsules or acetretin tablets - these lower the immune system and may sometimes help. Only used in extreme cases.
- Oral symptoms (symptoms in the mouth) - the doctor may prescribe steroid lozenges or mouth washes if mouth ulcer symptoms are uncomfortable. The tablets are dissolved in water and the patient swills the solution in his/her mouth for a few minutes, four to five times a day. Fortunately, oral lichen planus causes minimal problems and treatment is not usually required. Oral hygiene is sometimes poor among patients with pain inside their mouths, increasing the risk of gum diseases and tooth decay - it is important to maintain good oral hygiene. Talk to your doctor or dentist about this, and make sure you go to your scheduled dental visits.
- Lichen planus of the mucous membranes - treatment is difficult to get right and may take years. The doctor may prescribe oral corticosteroids as well as topical corticosteroids.
What are the possible complications of lichen planus?After the rash has gone there may be permanent brown or grey marks on the skin - the darker the patient's skin is the more noticeable they will be.
Persistent skin lesions and mouth ulcers may slightly raise the risk of developing cancer (rare).
Leukoplakia is a white or gray patch that develops on the tongue or the inside of the cheek. It is the mouth's reaction to chronic irritation of the mucous membranes of the mouth. Leukoplakia patches can also develop on the female genital area; however, the cause of this is unknown.
The growth can occur at any time in your life, but it is most common in the elderly.
"Hairy" leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with HIV, have AIDS, or AIDS-related complex. It consists of fuzzy, hence the name "hairy," white patches on the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if your immune system is not working properly, and may be one of the first signs of infection with the HIV virus.What Causes Leukoplakia?
- Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures that rub against your cheek or gum
- Chronic smoking, pipe smoking, or other tobacco use
- Sun exposure to the lips
- Oral cancer, although rare
- HIV or AIDS
The presence of white or gray colored patches on your tongue, gums, roof of your mouth, or the inside of the cheeks of your mouth may be a sign of leukoplakia. The patch may have developed slowly over weeks to months and be thick, slightly raised, and may eventually take on a hardened and rough texture. It usually is painless, but may be sensitive to touch, heat, spicy foods, or other irritation.