Acute oral ulcerations
Nathaniel S. Treister, DMD, DMSc and
Mark A. Lerman, DMD
 |
THE CHALLENGE
|
|---|
A 50-year-old woman was referred to the Center for Oral Disease at Brigham and Women’s Hospital, Boston, for evaluation and treatment of painful oral ulcerations. Four days before, she had become aware of discomfort while eating, with salad dressing especially causing her mouth to burn. The following day, she broke out in ulcerations (Figures 1
and 2) and developed what she reported as the worst pain that she had ever experienced. She sought treatment in her local emergency department over the weekend, received a prescription for an acetaminophen and oxycodone solution and a so-called "magic mouthwash" (bismuth salicylate, lidocaine and diphenhydramine hydrochloride, in equal parts) for pain, and was referred to the clinic the following Monday morning.
Clinical examination revealed multiple ulcerations involving the labial and buccal mucosa, the dorsal and ventrolateral surfaces of the tongue, the gingivae and the hard palate. There were no extra-oral skin or mucosal findings, and her medical history was significant only for hypothyroidism, for which she took levothyroxine. She denied any history of cold sores and reported having only occasional canker sores (one or two per year). A complete blood cell count with differential was within normal limits, and the clinician obtained a viral culture by swabbing the lesions throughout the oral cavity.
|
Can you make the diagnosis?
|
|---|
- erythema multiforme
- oral lichen planus
- herpetic gingivostomatitis
- aphthous stomatitis
- pemphigus vulgaris
|
THE DIAGNOSIS
|
|---|
C. herpetic gingivostomatitis
Primary infection with herpes simplex virus type 1 (HSV-1) generally occurs in the oral cavity before the age of 10 years. Herpes may be transmitted to someone previously uninfected by a host with symptomatic active lesions or during asymptomatic periods of viral shedding. A social history revealed that the patient recently had been divorced and had begun dating someone new, with whom she had spent the weekend before the onset of her symptoms. According to the patient, the man had admitted to a history of herpes labialis.
Although most HSV-1 infections are subclinical, a small percentage of patients develop primary herpetic gingivostomatitis.1 Typical symptoms include abrupt onset of fever, anorexia, irritability and intense mouth pain. Patients develop oral lesions of the attached and movable mucosal surfaces in which vesicles develop and quickly break down, coalescing to form large painful ulcerations. The gingivae become erythematous and tender.
Although most cases arise when patients are between the ages of 6 months and 5 years, primary infection occasionally is seen in much older people. A case of herpetic gingivostomatitis has been reported in a 70-year-old patient, although it is unclear whether this was truly a primary infection or an atypical manifestation of a recurrence.2 When seen in adults, primary HSV infection may present as pharyngotonsillitis, with lesions restricted to the palatine tonsils and posterior oropharynx, along with symptoms of sore throat, fever, malaise and headache.3 In younger patients, a clinical diagnosis usually can be made by means of signs and symptoms alone; however, in older patients, such as in this case, thorough and candid medical and social histories are essential. The viral culture obtained for this patient was positive for HSV, but on the basis of the patient’s history and the clinical presentation, the clinician initiated treatment empirically.
Primary herpetic gingivostomatitis is a self-limiting condition, and symptoms in otherwise healthy people can be expected to resolve independent of treatment within one to two weeks. The duration and severity of symptoms may be reduced if treatment with antiviral medication is initiated within the first two to three days of symptoms, but the diagnosis often is not made until later in the course of the illness.4,5 Regardless, the potential symptom relief for the patient may make it worthwhile to prescribe acyclovir or valacyclovir at any stage. In addition, pain management with topical and systemic medications, including opioid analgesics, must be provided. Patients are advised to stay well-hydrated, ensure adequate nutritional intake and take antipyretics to control fever. In this case, the patient was treated with acyclovir (200 milligrams/5 milliliters) 5 mL five times per day for 10 days, viscous lidocaine as needed and an oxycodone-acetaminophen combination elixir (5 mg/325 mg/5 mL) 10 mL every four to six hours as needed. With this regimen, her condition improved rapidly (Figure 3), and she was able to maintain adequate oral intake.
|
DIFFERENTIAL DIAGNOSIS
|
|---|
The differential diagnosis for acute onset of multiple oral ulcerations is extensive and requires a detailed history, careful clinical examination and, often, laboratory tests including culture, biopsy and serology. Erythema multiforme is a blistering condition of rapid onset that targets the mucous membranes and skin. The etiology is believed to be a hypersensitivity reaction to either a medication (for example, penicillin) or to HSV in patients with a positive history of HSV, especially when herpes labialis precedes the onset of lesions. Symptoms include fever, malaise, sore throat, cough and headache, followed by cutaneous and oral lesions. Skin lesions may manifest as flat or raised red lesions with concentric rings arranged in a "target" pattern, typically on the extremities. Oral lesions, which may develop in the absence of skin lesions, are seen in 35 to 65 percent of patients and manifest as large ulcers that may appear deeper and more irregular than those seen in primary HSV.5 Crusting of the lips is a classic finding. In contrast with areas typically affected by herpetic gingivostomatitis, the gingivae and hard palate rarely are affected in the manner observed in this patient.
Oral lichen planus is a T cell–mediated oral inflammatory condition. The erosive form of the disease may manifest with extensive ulcerations of the oral mucosa, but it rarely involves the lips. Fine white striations typically are seen on the buccal mucosa, gingiva or lateral aspect of the tongue. The long-standing nature of these lesions and their tendency to wax and wane also may help distinguish them from herpetic gingivostomatitis and other diseases of more rapid onset.6
Aphthous stomatitis is the most common non-infectious condition of the oral mucosa seen in humans.7 It is seen in children and adults and affects approximately 25 percent of the population. In most cases, aphthous ulcers manifest as solitary ulcerative lesions that typically heal within seven to 10 days. Only rarely does this condition involve the keratinized mucosal surfaces, and patients seldom have acute multiple lesions.
Pemphigus vulgaris is an autoimmune disorder in which antibodies target the desmosomes, causing the epithelial cells to separate from one another in the skin and mucosa. Nearly all patients develop oral lesions, with the buccal and labial mucosa, tongue and palate being the most commonly affected sites.8 Vesicles and bullae rupture quickly, leaving irregular ulcers. Desquamative gingivitis is a common finding. With an accurate history, pemphigus vulgaris—as well as other autoimmune vesiculobullous disorders such as mucous membrane pemphigoid—generally can be distinguished from herpetic gingivostomatitis by the more gradual progressive onset and lack of prodromal symptoms.
|
CONCLUSION
|
|---|
The diagnosis of primary herpetic gingivostomatitis often can be made on the basis of the clinical manifestation and history alone. When in doubt, cytological smear, viral culture or biopsy of active lesions may help confirm the diagnosis. Although herpetic gingivostomatitis is a self-limiting disease, supportive care is critical, and antiviral medications may help shorten the duration and severity of the condition, particularly when their use is initiated within the first few days of the appearance of symptoms. When acute onset of oral ulcers is encountered in an older patient, thorough medical and social histories are essential in arriving at a definitive diagnosis and initiating appropriate treatment.
|
FOOTNOTES
|
|---|
Dr. Treister is an attending oral medicine specialist, Division of Oral and Maxillofacial Surgery, Oral Medicine and Dentistry, Brigham and Women’s Hospital, 1620 Tremont St., Suite BC-3-028, Boston, Mass. 02120, e-mail "ntreister{at}partners.org", and an instructor, Division of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston. Address reprint requests to Dr. Treister.
Dr. Lerman is an attending oral pathologist, Division of Oral and Maxillofacial Surgery, Oral Medicine and Dentistry, Brigham and Women’s Hospital, Boston, and an instructor, Division of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston.
|
REFERENCES
|
|---|
- Chauvin PJ, Ajar AH. Acute herpetic gingivostomatitis in adults: a review of 13 cases, including diagnosis and management. J Can Dent Assoc 2002;68(4):247–51.[Medline]
- MacPhail L, Greenspan D. Herpetic gingivostomatitis in a 70-year-old man. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(1):50–2.[Medline]
- Vestey JP, Norval M. Mucocutaneous infections with herpes simplex virus and their management. Clin Exp Dermatol 1992;17(4): 221–37.[Medline]
- Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ 1997;314(7097):1800–3.[Abstract/Free Full Text]
- Lozada-Nur F, Gorsky M, Silverman S Jr. Oral erythema multiforme: clinical observations and treatment of 95 patients. Oral Surg Oral Med Oral Pathol 1989;67(1):36–40.[Medline]
- Greenberg MS, Glick M, eds. Burket’s oral medicine: Diagnosis and treatment. 10th ed. Hamilton, Ontario, Canada: BC Decker; 2003:58.
- Ship JA. Recurrent aphthous stomatitis: an update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81(2):141–7.[Medline]
- Bystryn JC, Rudolph JL. Pemphigus. Lancet 2005;366(9479):61–73.[Medline]
This article has been cited by other articles:
|
|
|
|
 
S. S. DeRossi, G. Salazar, J. Sarin, and F. Alawi
Chronic Lesions of the Gingiva and Mucosa
J Am Dent Assoc,
December 1, 2007;
138(12):
1589 - 1592.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. E. Albrecht
ACUTE ORAL ULCERS
J Am Dent Assoc,
August 1, 2007;
138(8):
1062 - 1062.
[Full Text]
[PDF]
|
|
|
TOP
THE CHALLENGE
Can you make the...
