vesicular, bullous or ulcerative lesions of the oral mucosa

Etiology: 1) viral infection a) herpes simplex - primary acute herpes gingivostomatitis - herpes simplex (type 1, rarely type 2) - lips & oral mucosa - vesicles, painful - spontaneous resolution in 10-14 days, unless secondary infection - recurrent herpes labialis - mucocutaneous junction of lip - groups of vesicles, may be painful - spontaneous resolution in 1 week, unless secondary infection - recurrent intraoral herpes simplex - palate & gingiva - vesicles, painful - spontaneous resolution in 1 week b) Varicella zoster - chickenpox - gingiva & oral mucosa - skin lesions, mucosal vesicles - spontaneous resolution in 2 weeks - shingles - cheek, tongue, gingiva, palate - unilateral vesicles &/or ulcers - gradual resolution without scarring c) Epstein-Barr virus (infectious mononucleosis) - oral mucosa - small oral ulcers precede lymphadenopathy, gingival bleeding, petechiae at junction of hard & soft palate - oral lesions disappear during convalescence d) papillomavirus (warts) - anywhere on oral mucosa - single or multiple papillary lesions - lesions grow rapidly & spread e) coxsackievirus - herpangina - oral mucosa, pharynx, tongue - vesicles, fever, sore throat - generally in children < 4 years of age - hand, foot & mouth disease - oral mucosa, pharynx - oropharyngeal vesicles, painful, fever - spontaneous resolution in 2-4 weeks f) primary HIV infection - gingiva, palate, pharynx - acute gingivitis, oropharyngeal ulceration 2) bacterial infection a) acute necrotizing ulcerative gingivostomatitis - ulceration & necrosis of gingival papillae - painful, bleeding gingiva, foul breath b) syphilis - congenital syphilis - palate, jaws, tongue, teeth - mucous patches, fissures in corners of mouth - primary syphilis (chancre) - lesions appear where organism enter body - small papule developing into large, painless ulcer - secondary syphilis - oral mucosa, palate, comissures of mouth - maculopapular lesions 5-10 mm with central ulceration - tertiary syphilis - palate & tongue - gummatous infiltration, ulceration & fibrosis c) gonorrhea - dryness, burning of mouth followed by pharyngitis - dry mouth, foul odor d) tuberculosis - tongue, tonsillar area, soft palate - solitary irregular ulcer with perisistent exudate 3) fungal infection a) cervicofacial actinomycosis - floor of mouth, face & neck - resembles pyogenic abscess b) histoplasmosis - any area of mouth esp. tongue, gingiva, palate - numerous small nodules, may ulcerate, fever c) candidiasis - any area of oral mucosa - pseudomembranous form with white patches easily wiped off leaving red, bleeding, sore surface - erythematous form is flat & red - rarely candidal leukoplakia (does NOT rub off) - angular cheilitis 4) dermatologic disease a) mucous membrane pemphigoid - mucous membrane of oral cavity - painful, grayish-white collapsed vesicles or bullae - gingival lesions desquamate, leaving ulcerated area b) erythema multiforme (Stevens-Johnson syndrome) - intraoral bullae surrounded by inflammatory area - may be signs of severe systemic toxicity c) pemphigus vulgaris - ruptured bullae & ulcerated oral areas - mostly in older adults d) lichen planus - white striae in mouth - oral mucosal ulcers & erosive gingivitis (uncommon) 5) neoplasm a) squamous cell carcinoma - most commonly on lower lip, tongue, floor of mouth - ulcer, failure to heal, pain not prominent - tend to arise from areas of leukoplakia or in smooth or atrophic tongue b) acute leukemia - gingiva - swelling, ulceration, hyperplasia, necrosis, hemorrhage - deep ulcers may occur elsewhere on mucosa complicated by secondary infection c) lymphoma - gingiva, palate, tongue & tonsillar area - elevated, ulcerated area, may proliferate rapidly - swelling of regional lymph nodes d) metastatic tumors - generally in premolar-molar area of mandible - destructive progression, pain & numbness of lower lip - evidence of malignancy apparent in other organ system 6) other conditions a) recurrent aphthous ulcers - anywhere on non-keratinized oral mucosa - painful ulcers (single or clusters) with surrounding erythema, 1-15 mm in diameter - lesions heal in 1-2 weeks, but may recur monthly or several times/year b) Behcet's syndrome - multiple ulcers - ulcers may persist for several weeks & heal without scarring - manifestations of disease in other organ systems c) traumatic ulcers

References

Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 200-202