HERPES SIMPLEX VIRUS type I, or rarely type 2, presents with fever and widespread confluent painful oral ulcers. After spontaneous resolution, the virus remains latent and recurs as herpes labialis (cold sores).
HAND, FOOT AND MOUTH DISEASE due to Coxsackie A virus produces mouth vesicles, usually in children. No treatment is required. Herpes zoster involving the fifth cranial nerve can produce unilateral vesicular lesions .
RECURRENT APHTHOUS ULCERATION of unknown aetiology affects approximately 20% of the population and is characterized by recurrent episodes of painful oral ulcers. There are three main clinical types:
• Minor aphthae are 2-4 mm ulcers which heal in 4-14 days without scarring
• Major aphthae are larger and take longer to heal (2- 10 weeks), sometimes with scarring
• Herpetiform ulcers in which many (10-100) tiny ulcers coalesce to form large ulcers
The term ‘herpetiform’ is purely descriptive and does not imply an infective aetiology. The ulcers are sometimes associated with gastrointestinal disease, notably Crohn’s disease, ulcerative colitis and coeliac disease. Other diseases associated with oral ulcers include Behcet’s disease, Reiter’s disease and systemic lupus erythematosus.
Deficiencies of iron, folic acid and vitamin B12have been noted in some patients, but in most no cause is found. Topical corticosteroids may lessen the duration and severity of an attack. The natural history is for the attacks to occur less frequently as the patient ages. Trauma, sharp teeth or ill-fitting dentures are common causes of all ulcers. Ulcers due to syphilis and tuberculosis are seen in developing countries and rarely in the UK.
SQUAMOUS CELL CARCINOMA. This presents as an indolent ulcer with surrounding induration mainly seen on the tongue and the floor of the mouth. Aetiological factors include tobacco and alcohol, particularly spirits. It used to affect men, mainly in the 50-70 age bracket, but now younger patients or women without obvious risk factors are seen. Biopsy should be undertaken and treatment is with surgery and radiotherapy.
Pemphigus, bullous pemphigoid and benign mucous membrane pemphigoid all cause oral bullae. A severe form of erythema multiforme, known as the Stevens- Johnson syndrome, also has bullae affecting the oral mucosa and conjunctiva.
Oral white patches White lesions may be transient or persistent. Transient white patches are either due to Candida infection or are very occasionally seen in systemic lupus erythematosus. Oral candidiasis in adults is seen in seriously ill or immunocompromised patients, or following therapy with broad spectrum antibiotics or inhaled steroids. Local causes include mechanical, irritative or chemical trauma from drugs, e.g. aspirin. Leucoplakia describes white patches for which no local cause can be found. It is associated with alcohol, and particularly smoking, and is regarded as a premalignant condition. A biopsy should alwaysbe undertaken, histology showing alteration in the keratinization and dysplasia of the epithelium. Treatment with isotretinoin reduces disease progression. Oral lichen planus presents as white striae.
The tongue may be ulcerated in association with more general oral mucosal ulceration. A single ulcer may be malignant and this must be considered in any ulcer which persists for more than 3 weeks (see above). Loss of filliform papillae producing a smooth sore tongue (atrophic glossitis) can occur in patients with iron, vitamin B12or vitamin folate deficiency.A painful tongue without any evidence of abnormality is often psychological in nature, although deficiency states must be excluded.
Geographic tongue affects 10% of the population. There are discrete areas of depapillation on the dorsum of the tongue which change over a few days or even hours. Geographic tongue may be asymptomatic or the patient may complain of a sore tongue. The aetiology is unknown and there is no treatment other than reassurance.
The gum or gingiva is the tissue covering the alveolar process of the mandible and maxilla, and surrounds the necks of the teeth. Bleeding of the gums affects most of the adult population at some time and is due to gingivitis. This is an inflammatory process caused by failure to remove bacteria in the form of plaque from the toothgingival junction. Less commonly, bleeding may be associated with a general bleeding disorder. Patients with acute leukaemia, as well as immunocompromised patients often have severe gingivitis with bleeding. Acute ulcerative gingivitis (Vincent’s infection) occurs in the malnourished patient with poor dentition and in the immunosuppressed. It is characterized by ulceration and is usually restricted to the gingiva, particularly the interdental papillae. Smears of affected areas show a mixed infection of fusobacteria and spirochaetes. Treatment is with oral metronidazole, 200 mg three times daily, for 1 week with accompanying good mouth and oral hygiene. Failure to treat this condition properly may predispose to a more widespread infection, particularly in the immunosuppressed, termed cancrum oris. Ulceration of the gums may occur in association with more generalized oral ulceration as described above. Generalized gum swellingis a feature of chronic gingivitisand may be a side-effect of pregnancy, various systemic diseases and some drugs, e.g. cyclosporin, phenytoin and nifedipine.
AIDS and the mouth
Oral lesions are frequently seen in patients with AIDS. Some of these lesions, e.g. Candida, aphthous ulceration and acute ulcerative gingivitis, simply reflect immunosuppression and are not specific for AIDS. The other lesions described are more specificfor AIDS. Kaposi’s sarcoma presents as red/blue or purple patches which may be perioral or in the mouth usually on the palate at the junction of the hard and soft palate. Hairy leucoplakia is characterized by white patches which cannot be removed, usually affecting the lateral surface of the tongue. There is intense epithelial hyperplasia giving rise to a hairy appearance. Hairy leucoplakia is an indicator of a poor prognosis in these patients.