My apologies for a slow past two weeks of blogging. Last week I attended the ADA's Evidence Based Dentistry Champions Conference in Chicago. I learned a ton about dental research and evidence and ways to incorporate that into daily practice. I am going to start a series of articles about Evidence Based Dentistry which might be a bit dry considering the content. We all remember our research classes in dental school. The material just isn't that enthralling. I have been wondering on how to start the series of articles when something interesting walked into my office this morning. I feel this case will help me illustrate how EBD (evidence based dentistry) can be used in private practice and also be a colorful case study to help make the dry subject more palatable. This will be the first in the series, so be looking for more this week. So here we go...
Andy presented to my office this morning complaining of "painful blisters on the inside and outside of my mouth!" According to the patient, the pain and "blisters" started about 3 days ago. He was vacationing at the gulf coast with some friends and he suspects that someone else used his tooth brush. He reports a tingling feeling in his mouth several days ago, which preceeded the pain and "blisters" by a day or so. Here are some photographs of Andy which I just took.
Andy has reported never having anything like this ever. He is a healthy adult male in his mid-30's. An extraoral exam reveals multiple fluid-filled vesicles on his left side surrounding his vermillion border and onto his cheek. Intraorally, Andy has multiple yellowish mucosal ulcerations on both movable and attached oral mucosa. The lesions appear on both the dorsal and ventral aspects of the tongue. Andy reports feeling "under the weather" after the lesions began forming.
Obviously, my differential diagnosis includes primary acute herpetic gingivostomatitis and herpes zoster. Due to the feeling of malaise and possible fever at the time the lesions appeared leads me to believe the diagnosis is primary acute herpetic gingivostomatitis.
Now, how should I treat this condition? I quickly visited ADA's Evidence Based Dentistry Website and searched for "primary herpetic gingivostomatitis." I found this entry which is a systematic review of using acyclovir for primary herpetic gingivostomatitis. This particular review is housed in the Cochrane Database for systematic reviews. I will discuss the importance of these two features in the next blog entry. The summary of the review itself can be found here.
The citation is: "Acyclovir for treating primary herpetic gingivostomatitis." Nasser M, Fedorowicz Z, Khoshnevisan MH, Shahiri Tabarestani M. Evid Based Dent. 2008;9(4):117.
The review comes to the conclusion that "We found two relevant trials in this systematic review, only one of them could provide some weak evidence that acyclovir is an effective treatment in reducing the number of oral lesions, preventing the development of new extraoral lesions, decreasing the number of individuals with difficulties experienced in eating and drinking and reducing hospital admission for children under 6 years of age with primary herpetic gingivostomatitis."
One thing interesting about really analyzing good solid dental evidence is that there is a lack of good studies in many areas. Much evidence that we take for granted is considered "weak" by dental researchers. Many times, we must base our treatment decisions on "weak" data. So what did I do? I gave Andy a prescription for Valtrex 500mg (1 BID for 10 days). I also prescribed him some medications for palliative treatment. One was Motrin 800mg, the other a suspension called Pink Magic. Pink Magic is a suspension containing equal parts viscous lidocaine, Maalox, and diphenhydramine. Both of these are intended to make the patient more comfortable while the lesions heal.
Over the next week or so I will post articles about levels of evidence, deciphering good studies from poor studies, and how to find evidence.