Oral Lesions

Recurrent oral erosions are most often secondary to herpes simplex virus or idiopathic aphthous stomatitis. A thorough review of systems and complete skin exam are the best tools to assure diagnostic accuracy, particularly in light of the fact that serious medical conditions may manifest first as oral lesions. Referral to an oral surgeon, otorhinolaryngologist, or dermatologist is necessary if a definitive diagnosis cannot be determined.

Differential Diagnosis

• Aphthous stomatitis
  –Idiopathic
  –Recurrent, shallow, painful, spontaneously resolving oral ulcers
• Herpes stomatitis
  –Due to a primary outbreak of HSV-1
  –Severe gingivostomatitis with pain, redness, and erosions around the gum line
  –Recurrent oral HSV (“cold sores”) often occur at the lip border
  –Stress, sun exposure, and many other factors contribute to flare-ups
• Self-limited viral disease (e.g., herpangina, hand-foot-mouth disease)
  –Most often seen in children
  –Prodrome of malaise and fever followed by a 5–10 day outbreak of oropharyngeal erosions or vesicles is common
  • Chemotherapy drugs (especially 5-FU and methotrexate)
  • Squamous cell carcinoma should always be considered if a nonhealing ulcer or oral erosion is noted
  • Bullous diseases (e.g., pemphigoid, pemphigus, lichen planus)
    –Recurrent painful oral ulcers and erosions
    –Evaluate for other skin rashes suggestive of these disorders
    • Behçet syndrome
      –Uncommon but well-known cause of oral ulcers
      –Patients must exhibit other symptoms (e.g., uveitis, CNS problems, GI complaints, genital ulcers) before this diagnosis can be made
    • Allergic contact dermatitis to amalgams in dental work may result in buccal tenderness
    • Erythema multiforme (Stevens-Johnson syndrome)
      –Characterized by oral ulcers, ocular involvement, and simultaneous targetoid, erythematous, or bullous skin lesions
      –May be triggered by HSV infection, Mycoplasma infection, or drugs (e.g., phenytoin, sulfonamides)
      • Primary syphilis
        –Painless chancre
      • Agranulocytosis or leukopenia
      • Histoplasmosis (especially in immunosuppressed patients)

      Workup and Diagnosis

      • Detailed history and physical examination
        –Associated symptoms (e.g., fever, prodrome)
        –Review the patient's past medical history and medication list
        –If ulcers occur in the same location with every episode, oral HSV is likely
        –Is the patient sexually active (consider HIV, immunosuppression, or syphilis)
        –Perform a thorough skin exam to evaluate for rashes or other mucosal lesions (ocular, urethral, or perianal)
        –Lacy white plaques on the tongue or buccal mucosa may suggest lichen planus
        –Ocular or anogenital complaints can be suggestive of Behçet syndrome, pemphigus, or pemphigoid
      • Initial evaluation includes a viral swab for culture and/or serum for HSV-1 IgG detection to diagnose HSV, and consider an RPR and CBC to rule out syphilis and leukopenia, respectively
      • Consider a punch biopsy of the edge of an ulcer/erosion to determine if there are viral changes or cytologic atypia; or evidence of an autoimmune bullous disease
      • Recurrent aphthous stomatitis is a diagnosis of exclusion, but is also the most common diagnosis of recurrent painful oral ulcers after HSV

      Treatment

      • Orabase^® compounded with high-potency topical steroids (e.g., clobetasol) may offer symptomatic relief and increase speed of healing
      • “Magic mouthwash” may be used to swish and spit as necessary for relief (these may contain lidocaine, diphenhydramine, antacids, and even liquid tetracycline)
      • Aphthous stomatitis: Intralesional triamcinalone injections are painful but very helpful
        –Lesions spontaneously resolve within 2 weeks
        • Recurrent herpes stomatitis: Episodic treatment with 1–7 day courses of oral antivirals (e.g., acyclovir) can shorten the duration of the episode and speed healing
          –These are efficacious only if started within 24 hours of the onset of the prodrome (often tingling or pain at the site of eruption occurs hours before onset)
          –Chronic suppressive therapy with oral antivirals may be indicated if recurrences are frequent
        • Bullous diseases: Corticosteroids (topical or oral), cyclosporine, and even thalidomide

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X