Oral Cavity

Lesions of aphthous stomatitis are small (2 to 5 mm), shallow, well-demarcated, punched-out erosions.
Typically aphthae have a ring of erythema with a gray or yellowish center (Figs. 21.1-21.3).
Lesions are painful and tend to heal in 4 to 14 days, a duration similar to that of HSV lesions.
Patients with human immunodeficiency virus (HIV) or Behçet disease may develop aphthous stomatitis lesions that tend to be larger more persistent, painful, and extensive (Fig. 21.4).
Most episodes heal spontaneously, only to recur unexpectedly.
Most often arise on the buccal, labial, and gingival mucosa, as well as on the tongue.

Diagnosis ⬆ ⬇

The diagnosis is made clinically.

Differential Diagnosis

Primary HSV Infection (Discussed in Chapters 6 and 17)

Oral erosions that are often indistinguishable from aphthous stomatitis are sometimes seen in primary herpes simplex virus (HSV) infections.
Primary herpes gingivostomatitis occurs mainly in infants and young children, often subclinically, mild and unnoticed, but they can be severe, although less severe than recurrences.
Fever, malaise, restlessness, and excessive drooling are common.

Autoimmune Bullous Diseases such as Pemphigus Vulgaris and Bullous Pemphigoid

Chronic; bullous lesions often present elsewhere on the body.

Cyclic Neutropenia

Dominantly inherited recurrent oral erosions/ulcers that occur every 3 weeks and last 3 to 6 days at a time.
Ulcers result from changing rates of neutrophilic cell production by the bone marrow.

Also consider:

Systemic Lupus Erythematosus (see below)
Behçet Disease

Management

Therapeutic options include the following:

Application of viscous lidocaine(Xylocaine) to lesions.
Vanceril (beclomethasone dipropionate) aerosol can be sprayed directly on lesions.
Superpotent topical steroids may be applied directly to lesions and held there by pressure with a finger in a rubber glove or applied with a cotton swab.
Tetracycline suspension (250 mg/tsp); patients should “swish and swallow.”
Diphenhydramine (Benadryl) suspension; patients are directed to “gargle and spit.”
Tacrolimus 0.1% ointment (Protopic) and pimecrolimus1% cream (Elidel) applied at bedtime may accelerate healing.
Silver nitrate, applied with an applicator stick directly to lesions, also can promote healing (Fig. 21.5).
Intralesional corticosteroid injections or a brief course of systemic corticosteroids are effective in reducing pain and healing lesions in patients with large, persistent, painful ulcers.
Thalidomide has been used with some success in healing large, recalcitrant, painful, persistent aphthae in persons with HIV infection.

Helpful Hint

A single, nonhealing ulcer (lasting more than 2 months) should undergo biopsy to rule out squamous cell carcinoma.

Point to Remember

The vast majority of recurrent intraoral ulcers in immunocompetent patients are canker sores, not HSV lesions; recurrent HSV infection are unlikely to occur inside the mouth.

Other Information ⬆

Aphthous Stomatitis

Commonly referred to as “canker sores,” aphthous ulcers are a common, recurrent problem consisting of shallow erosions of the mucous membranes.
They are seen in children and adults and appear to be more common in women than men.
Aphthous stomatitis has no known cause, but an immune mechanism is considered the most likely contributory factor.
Patients often ascribe recurrences to psychological stress or local trauma.
Women may correlate them with their menstrual cycle.

Oral Lichen Planus (see also Chapter 15: InflAMmatory Eruptions of Unknown Cause)

Clinical Manifestations

A white, lacy network of lesions are present on the buccal mucosa (see Fig. 15.19), tongue, or gums.
When erosive or ulcerative, lesions are painful and interfere with eating (Fig. 21.6).
Evidence of lichen planus may or may not be present elsewhere on the body.

Diagnosis

Diagnosis can be made on clinical examination especially when cutaneous lesions of lichen planus are evident.
Biopsy, if necessary.

Differential Diagnosis

White oral lichen planus lesions are often mistaken for:
- Oral candidiasis
- Oral leukoplakia
- Normal bite lines (seeFig. 15.23)

Management

Topically applied steroid gels or ointments to affected sites provide symptomatic relief.
Intralesional triamcinolone into affected areas may be useful for localized disease.
If necessary, systemic steroids such as prednisone may be prescribed for a few weeks or longer.
Topical tacrolimus 0.1% ointment (Protopic) may be effective.
Preventive dental hygiene care is also very important.

Systemic Lupus Erythematosus (discussed in Chapter 34: Cutaneous Manifestations of Systemic Disease)

Clinical Manifestations

Painless, shallow oral ulcers, most often occur on the hard and soft palate.
Lesions appear as macules that later transform into irregular erosions and ulcers and often heal with scarring.
Purpuric lesions such as ecchymoses and petechiae may occur.

Management

As with oral lichen planus (described above), erosions and ulcers can be treated topically with steroid gels or ointments, topical tacrolimus ointment, intralesional steroid injections, or if necessary, systemic steroids.

Outline
Aphthous Stomatitis
Oral Lichen Planus (see also Chapter 15: InflAMmatory Eruptions of Unknown Cause)
Systemic Lupus Erythematosus (discussed in Chapter 34: Cutaneous Manifestations of Systemic Disease)

section name header

Clinical Manifestations ⬇

Diagnosis ⬆ ⬇

Other Information ⬆