MARTIN S. GREENBERG, DDS
▼ THE PATIENT WITH ACUTE MULTIPLE LESIONS
Herpesvirus Infections Primary Herpes Simplex Virus Infections Coxsackievirus Infections Varicella-Zoster Virus Infection Erythema Multiforme Contact Allergic Stomatitis Oral Ulcers Secondary to Cancer Chemotherapy Acute Necrotizing Ulcerative Gingivitis
▼ THE PATIENT WITH RECURRING ORAL ULCERS
▼ THE PATIENT WITH ACUTE MULTIPLE LESIONS
Herpesvirus Infections Primary Herpes Simplex Virus Infections Coxsackievirus Infections Varicella-Zoster Virus Infection Erythema Multiforme Contact Allergic Stomatitis Oral Ulcers Secondary to Cancer Chemotherapy Acute Necrotizing Ulcerative Gingivitis
▼ THE PATIENT WITH RECURRING ORAL ULCERS
Recurrent Aphthous Stomatitis Behçet’s Syndrome Recurrent Herpes Simplex Virus Infection
▼ THE PATIENT WITH CHRONIC MULTIPLE LESIONS
Pemphigus Subepithelial Bullous Dermatoses Herpes Simplex Virus Infection in Immunosuppressed Patients
▼ THE PATIENT WITH SINGLE ULCERS
Histoplasmosis Blastomycosis Mucormycosis
A clinician attempting to diagnose an ulcerative or vesiculobullous disease of the mouth is confronted with the fact that many diseases have a similar clinical appearance. The oral mucosa is thin, causing vesicles and bullae to break rapidly into ulcers, and ulcers are easily traumatized from teeth and food, and they become secondarily infected by the oral flora. These factors may cause lesions that have a characteristic appearance on the skin to have a nonspecific appearance on the oral mucosa.
Mucosal disorders may occasionally be correctly diagnosed from a brief history and rapid clinical examination, but this approach is most often insufficient and leads to incorrect diagnosis and improper treatment. The history taking is frequently underemphasized, but, when correctly performed, it gives as much information as does the clinical examination. A detailed history of the present illness is of particular importance when attempting to diagnose oral mucosal lesions. A complete review of systems should be obtained for each patient, including questions regarding the presence of skin, eye, genital, and rectal lesions. Questions should also be included regarding symptoms of diseases associated with oral lesions; that is, each patient should be asked about the presence of symptoms such as joint pains, muscle weakness, dyspnea, diplopia, and chest pains. The clinical examination should include a thorough inspection of the exposed skin surfaces; the diagnosis of oral lesions requires knowledge of basic dermatology because many disorders occurring on the oral mucosa also affect the skin. Dermatologic lesions are classified according to their clinical appearance and include the following basic lesions:
1. Macules. Well-circumscribed, flat lesions that are noticeable because of their change from normal skin color. They may be red due to the presence of vascular lesions or inflammation, or pigmented due to the presence of melanin, hemosiderin, and drugs.
2. Papules. Solid lesions raised above the skin surface that are smaller than 1 cm in diameter. Papules may be seen in a wide variety of diseases including erythema multiforme simplex, rubella, lupus erythematosus, and sarcoidosis.
3. Plaques. Solid raised lesions that are over 1 cm in diameter; they are large papules.
4. Nodules. These lesions are present deep in the dermis, and the epidermis can be easily moved over them.
5. Vesicles. Elevated blisters containing clear fluid that are under 1 cm in diameter.
6. Bullae. Elevated blisterlike lesions containing clear fluid that are over 1 cm in diameter.
7. Erosions. Moist red lesions often caused by the rupture of vesicles or bullae as well as trauma.
8. Pustules. Raised lesions containing purulent material. 9. Ulcers. A defect in the epithelium; it is a well-circum-
scribed depressed lesion over which the epidermal layer has been lost.
10. Purpura. Reddish to purple flat lesions caused by blood from vessels leaking into the subcutaneous tissue. Classified by size as petechiae or ecchymoses, these lesions do not blanch when pressed.
11. Petechiae. Purpuric lesions 1 to 2 mm in diameter. Larger purpuric lesions are called ecchymoses.
A detailed history of the present illness is essential in making the diagnosis of oral mucosal disease. Three pieces of information that should be obtained early in the history will help the clinician rapidly categorize a patient’s disease and simplify the diagnosis: length of time the lesions have been present (acute or chronic lesions), past history of similar lesions (primary or recurrent disease), and number of lesions present (single or multiple). In this chapter, the diseases are grouped according to the information just described. This information serves as an excellent starting point for the student who is just learning to diagnose these disorders, as well as the experienced clinician who is aware of the potential diagnostic pitfalls.
The first section of this chapter describes acute multiple lesions that tend to occur only once, the second portion of the chapter covers recurring oral mucosal syndromes, and the third portion presents the patient with chronic multiple lesions. The final section describes diseases that present as chronic single lesions. It is hoped that classifying the disorders in this way will help the clinician avoid the common diagnostic problem of confusing viral infections with recurring oral syndromes, such as recurrent aphthous stomatitis, or disorders that present as chronic progressive disease, such as pemphigus and pemphoid.
3. Plaques. Solid raised lesions that are over 1 cm in diameter; they are large papules.
4. Nodules. These lesions are present deep in the dermis, and the epidermis can be easily moved over them.
5. Vesicles. Elevated blisters containing clear fluid that are under 1 cm in diameter.
6. Bullae. Elevated blisterlike lesions containing clear fluid that are over 1 cm in diameter.
7. Erosions. Moist red lesions often caused by the rupture of vesicles or bullae as well as trauma.
8. Pustules. Raised lesions containing purulent material. 9. Ulcers. A defect in the epithelium; it is a well-circum-
scribed depressed lesion over which the epidermal layer has been lost.
10. Purpura. Reddish to purple flat lesions caused by blood from vessels leaking into the subcutaneous tissue. Classified by size as petechiae or ecchymoses, these lesions do not blanch when pressed.
11. Petechiae. Purpuric lesions 1 to 2 mm in diameter. Larger purpuric lesions are called ecchymoses.
A detailed history of the present illness is essential in making the diagnosis of oral mucosal disease. Three pieces of information that should be obtained early in the history will help the clinician rapidly categorize a patient’s disease and simplify the diagnosis: length of time the lesions have been present (acute or chronic lesions), past history of similar lesions (primary or recurrent disease), and number of lesions present (single or multiple). In this chapter, the diseases are grouped according to the information just described. This information serves as an excellent starting point for the student who is just learning to diagnose these disorders, as well as the experienced clinician who is aware of the potential diagnostic pitfalls.
The first section of this chapter describes acute multiple lesions that tend to occur only once, the second portion of the chapter covers recurring oral mucosal syndromes, and the third portion presents the patient with chronic multiple lesions. The final section describes diseases that present as chronic single lesions. It is hoped that classifying the disorders in this way will help the clinician avoid the common diagnostic problem of confusing viral infections with recurring oral syndromes, such as recurrent aphthous stomatitis, or disorders that present as chronic progressive disease, such as pemphigus and pemphoid.