Acute oral ulcerations

Nathaniel S. Treister and Mark A. Lerman

J Am Dent Assoc 2007;138;499-501

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CLINICAL PRACTICE DIAGNOSTIC CHALLENGE

Acute oral ulcerations

Nathaniel S. Treister, DMD, DMSc; Mark A. Lerman, DMD

THE CHALLENGE dramine hydrochloride, in equal parts) for pain, and

was referred to the clinic the followingAMonday
D
A
A 50-year-old woman was referred to the Center for morning. J

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✷ ✷
Oral Disease at Brigham and Women’s Hospital, Clinical examination revealed multiple ulcera-®

Boston, for evaluation and treatment of painful oral tions involving the labial and buccal mucosa, the

N
CON

IO
ulcerations. Four days before, she had become aware dorsal and ventrolateral surfaces of the tongue, the

T
T

A
N

I
of discomfort while eating, with salad dressing espe- gingivae and the hard palate. ThereUwere no Cextra-
A ING EDU 1
cially causing her mouth to burn. The following day, oral skin or mucosal findings, and R herT I C L E his-
medical
she broke out in ulcerations (Figures 1 and 2) and tory was significant only for hypothyroidism, for
developed what she reported as the worst pain that which she took levothyroxine. She denied any his-
she had ever experienced. She sought treatment in tory of cold sores and reported having only occa-
her local emergency department over the weekend, sional canker sores (one or two per year). A complete
received a prescription for an acetaminophen and blood cell count with differential was within normal
oxycodone solution and a so-called “magic mouth- limits, and the clinician obtained a viral culture by
wash” (bismuth salicylate, lidocaine and diphenhy- swabbing the lesions throughout the oral cavity.

Figure 1. Multiple ulcerated vesicles and bullae of the lips and floor Figure 2. Widespread ulcers can be seen on the labial mucosa
of mouth. and along the gingival margin.

Can you make the diagnosis?

A. erythema multiforme D. aphthous stomatitis

B. oral lichen planus E. pemphigus vulgaris
C. herpetic gingivostomatitis

JADA, Vol. 138 http://jada.ada.org April 2007 499

Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE DIAGNOSTIC CHALLENGE
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 trans-
mitted to someone previously uninfected by a host
with symptomatic active lesions or during asymp-
tomatic 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 subclin-
ical, a small percentage of patients develop pri-
mary herpetic gingivostomatitis.1 Typical symp-
toms 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 erythe-
matous and tender.
Although most cases arise when patients are
between the ages of 6 months and 5 years, pri-
mary 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 infec-
tion 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 essen-
tial. 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 inde-
pendent 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
500 JADA, Vol. 138 http://jada.ada.org April 2007
Copyright ©2007 American Dental Association. All rights reserved.
until later in the course of the illness.4,5 Regard-
less, the potential symptom relief for the patient
may make it worthwhile to prescribe acyclovir or
valacyclovir at any stage. In addition, pain man-
agement 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 mil-
ligrams/5 milliliters) 5 mL five times per
day for 10 days, viscous lidocaine as needed and
an oxycodone-acetaminophen combination elixir
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(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 mul-
tiple 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, fol-
lowed 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 con-
trast 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

Figure 3. Resolution of the lesions.
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 gingivostom-
atitis 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 popula-
tion. 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 sur-
faces, and patients seldom have acute multiple
lesions.
Pemphigus vulgaris is an autoimmune dis-
order in which antibodies target the desmo-
somes, 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—
Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE DIAGNOSTIC CHALLENGE
as well as other autoimmune vesiculobullous dis-
orders such as mucous membrane pemphigoid—
generally can be distinguished from herpetic gin-
givostomatitis by the more gradual progressive
onset and lack of prodromal symptoms.
CONCLUSION
The diagnosis of primary herpetic gingivostom-
atitis often can be made on the basis of the clin-
ical 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 dura-
tion and severity of the condition, particularly
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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. ■
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@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.
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