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- Chapter 032. Oral Manifestations
of Disease
(Part 3)
Diseases of the Oral Mucosa
Infection
Most oral mucosal diseases involve microorganisms (Table 32-1).
Table 32-1 Vesicular, Bullous, or Ulcerative Lesions of the Oral
Mucosa
Condition Usual Clinical Course
Location Features
- Viral Diseases
Primary Lip and oral Labial Heals
acute herpetic mucosa (buccal, vesicles that spontaneously in 10–
gingivostomatitis gingival, lingual rupture and crust, 14 days. Unless
[herpes simplex mucosa) and intraoral secondarily infected,
virus (HSV) type 1, vesicles that lesions lasting >3
rarely type 2] quickly ulcerate; weeks are not due to
extremely painful; primary HSV
acute gingivitis, infection.
fever, malaise, foul
odor, and cervical
lymphadenopathy;
occurs primarily in
infants, children,
and young adults
Recurrent Mucocutane Eruption of Lasts about 1
herpes labialis ous junction of lip, groups of vesicles week, but condition
perioral skin that may coalesce, may be prolonged if
then rupture and secondarily infected.
- crust; painful to If severe, topical or
pressure or spicy oral antiviral may
foods reduce healing time.
Recurrent Palate and Small Heals
intraoral herpes gingiva vesicles on spontaneously in
simplex keratinized about 1 week. If
epithelium that severe, topical or oral
rupture and antiviral may reduce
coalesce; painful healing time.
Chickenpox Gingiva and Skin lesions Lesions heal
(varicella-zoster oral mucosa may be spontaneously within
virus) accompanied by 2 weeks.
small vesicles on
oral mucosa that
rupture to form
shallow ulcers;
may coalesce to
form large bullous
lesions that
- ulcerate; mucosa
may have
generalized
erythema
Herpes Cheek, Unilateral Gradual
zoster (reactivation tongue, gingiva, or vesicular eruptions healing without
of varicella-zoster palate and ulceration in scarring unless
virus) linear pattern secondarily infected;
following sensory postherpetic
distribution of neuralgia is common.
trigeminal nerve or Oral acyclovir,
one of its branches famcyclovir, or
valacyclovir reduce
healing time and
postherpetic
neuralgia
Infectious Oral mucosa Fatigue, Oral lesions
mononucleosis sore throat, disappear during
(Epstein-Barr malaise, fever, and convalescence; no
- virus) cervical treatment though
lymphadenopathy; glucocorticoids
numerous small indicated if tonsillar
ulcers usually swelling
appear several days compromises airway
before
lymphadenopathy;
gingival bleeding
and multiple
petechiae at
junction of hard
and soft palates
Herpangina Oral mucosa, Sudden Incubation
(coxsackievirus A; pharynx, tongue onset of fever, sore period 2–9 days;
also possibly throat, and fever for 1–4 days;
coxsackie B and oropharyngeal recovery uneventful
echovirus) vesicles, usually in
children under 4
years, during
summer months;
- diffuse pharyngeal
congestion and
vesicles (1–2 mm),
grayish-white
surrounded by red
areola; vesicles
enlarge and
ulcerate
Hand, foot, Oral mucosa, Fever, Incubation
and mouth disease pharynx, palms, and malaise, headache period 2–18 days;
(coxsackievirus soles with oropharyngeal lesions heal
A16 most vesicles that spontaneously in 2–4
common) become painful, weeks
shallow ulcers;
highly infectious;
usually affects
children under age
10
Primary Gingiva, Acute Followed by
- HIV infection palate, and pharynx gingivitis and HIV seroconversion,
oropharyngeal asymptomatic HIV
ulceration, infection, and usually
associated with ultimately by HIV
febrile illness disease
resembling
mononucleosis and
including
lymphadenopathy
Bacterial or Fungal Diseases
Acute Gingiva Painful, Debridement
necrotizing bleeding gingiva and diluted (1:3)
ulcerative characterized by peroxide lavage
gingivitis ("trench necrosis and provide relief within
mouth," Vincent's ulceration of 24 h; antibiotics in
infection) gingival papillae acutely ill patients;
and margins plus relapse may occur
lymphadenopathy
and foul odor
- Prenatal Palate, jaws, Gummatous Tooth
(congenital) tongue, and teeth involvement of deformities in
syphilis palate, jaws, and permanent dentition
facial bones; irreversible
Hutchinson's
incisors, mulberry
molars, glossitis,
mucous patches,
and fissures on
corner of mouth
Primary Lesion Small Healing of
syphilis (chancre) appears where papule developing chancre in 1–2
organism enters rapidly into a large, months, followed by
body; may occur on painless ulcer with secondary syphilis in
lips, tongue, or indurated border; 6–8 weeks
tonsillar area unilateral
lymphadenopathy;
chancre and lymph
nodes containing
spirochetes;
- serologic tests
positive by third to
fourth weeks
Secondary Oral mucosa Maculopapu Lesions may
syphilis frequently involved lar lesions of oral persist from several
with mucous mucosa, 5–10 mm weeks to a year
patches, primarily in diameter with
on palate, also at central ulceration
commissures of covered by grayish
mouth membrane;
eruptions occurring
on various mucosal
surfaces and skin
accompanied by
fever, malaise, and
sore throat
Tertiary Palate and Gummatous Gumma may
syphilis tongue infiltration of destroy palate,
palate or tongue causing complete
- followed by perforation
ulceration and
fibrosis; atrophy of
tongue papillae
produces
characteristic bald
tongue and
glossitis
Gonorrhea Lesions may Most More difficult
occur in mouth at pharyngeal to eradicate than
site of inoculation infection is urogenital infection,
or secondarily by asymptomatic; may though pharyngitis
hematogenous produce burning or usually resolves with
spread from a itching sensation; appropriate
primary focus oropharynx and antimicrobial
elsewhere tonsils may be treatment
ulcerated and
erythematous;
saliva viscous and
fetid
- Tuberculosis Tongue, A painless, Autoinnoculat
tonsillar area, soft solitary, 1–5 cm, ion from pulmonary
palate irregular ulcer infection usual;
covered with a lesions resolve with
persistent exudate; appropriate
ulcer has a firm antimicrobial therapy
undermined border
Cervicofacia Swellings in Infection Typically
l actinomycosis region of face, may be associated swelling is hard and
neck, and floor of with an extraction, grows painlessly;
mouth jaw fracture, or multiple abscesses
eruption of molar with draining tracks
tooth; in acute develop; penicillin
form resembles an first choice; surgery
acute pyogenic usually necessary
abscess, but
contains yellow
"sulfur granules"
(gram-positive
mycelia and their
- hyphae)
Histoplasmo Any area of Nodular, Systemic
sis the mouth, verrucous, or antifungal therapy
particularly tongue, granulomatous necessary to treat
gingiva, or palate lesions; ulcers are
indurated and
painful; usual
source
hematogenous or
pulmonary, but
may be primary
Candidiasis
(Table 32-3)
Dermatologic Diseases
Mucous Typically Painful, Protracted
membrane produces marked grayish-white course with
pemphigoid gingival erythema collapsed vesicles remissions and
- and ulceration; or bullae of full- exacerbations;
other areas of oral thickness involvement of
cavity, esophagus, epithelium with different sites occurs
and vagina may be peripheral slowly;
affected erythematous zone; glucocorticoids may
gingival lesions temporarily reduce
desquamate, symptoms but do not
leaving ulcerated control the disease
area
Erythema Primarily the Intraoral Onset very
multiforme minor oral mucosa and the ruptured bullae rapid; usually
and major skin of hands and surrounded by an idiopathic, but may
(Stevens-Johnson feet inflammatory area; be associated with
syndrome) lips may show trigger such as drug
hemorrhagic reaction; condition
crusts; the "iris," or may last 3–6 weeks;
"target," lesion on mortality with EM
the skin is major 5–15% if
pathognomonic; untreated
patient may have
- severe signs of
toxicity
Pemphigus Oral mucosa Usually With repeated
vulgaris and skin; sites of (>70%) presents occurrence of bullae,
mechanical trauma with oral lesions; toxicity may lead to
(soft/hard palate, fragile, ruptured cachexia, infection,
frenulum, lips, bullae and and death within 2
buccal mucosa) ulcerated oral years; often
areas; mostly in controllable with oral
older adults glucocorticoids
Lichen Oral mucosa White striae White striae
planus and skin in mouth; purplish alone usually
nodules on skin at asymptomatic;
sites of friction; erosive lesions often
occasionally causes difficult to treat, but
oral mucosal ulcers may respond to
and erosive glucocorticoids
gingivitis
- Other Conditions
Recurrent Usually on Single or Lesions heal
aphthous ulcers nonkeratinized oral clusters of painful in 1–2 weeks but
mucosa (buccal and ulcers with may recur monthly or
labial mucosa, floor surrounding several times a year;
of mouth, soft erythematous protective barrier
palate, lateral and border; lesions may with orabase and
ventral tongue) be 1–2 mm in topical steroids give
diameter in crops symptomatic relief;
(herpetiform), 1–5 systemic
mm (minor), or 5– glucocorticoids may
15 mm (major) be needed in severe
cases
Behçet's Oral mucosa, Multiple Oral lesions
syndrome eyes, genitalia, gut, aphthous ulcers in often first
and CNS mouth; manifestation; persist
inflammatory several weeks and
ocular changes, heal without scarring
ulcerative lesions
- on genitalia;
inflammatory
bowel disease and
CNS disease
Traumatic Anywhere Localized, Lesions
ulcers on oral mucosa; discrete ulcerated usually heal in 7–10
dentures frequently lesions with red days when irritant is
responsible for border; produced removed, unless
ulcers in vestibule by accidental biting secondarily infected
of mucosa,
penetration by a
foreign object, or
chronic irritation
by a denture
Squamous Any area in Ulcer with Invades and
cell carcinoma the mouth, most elevated, indurated destroys underlying
commonly on lower border; failure to tissues; frequently
lip, tongue, and heal, pain not metastasizes to
floor of mouth prominent; lesions regional lymph nodes
- tend to arise in
areas of
erythro/leukoplakia
or in smooth
atrophic tongue
Acute Gingiva Gingival Usually
myeloid leukemia swelling and responds to systemic
(usually superficial treatment of
monocytic) ulceration followed leukemia;
by hyperplasia of occasionally requires
gingiva with local radiation
extensive necrosis therapy
and hemorrhage;
deep ulcers may
occur elsewhere on
the mucosa
complicated by
secondary infection
Lymphoma Gingiva, Elevated, Fatal if
- tongue, palate and ulcerated area that untreated; may
tonsillar area may proliferate indicate underlying
rapidly, giving the HIV infection
appearance of
traumatic
inflammation
Chemical or Any area in White Lesion heals
thermal burns mouth slough due to in several weeks if
contact with not secondarily
corrosive agents infected
(e.g., aspirin, hot
cheese) applied
locally; removal of
slough leaves raw,
painful surface
Note: CNS, central nervous system.
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