Routine studies include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, and culture of any material that can be obtained from an ulceration if present. A therapeutic trial of antibiotics or antiviral medication can be done at this point. If this is unsuccessful, the patient should be referred to an oral surgeon or dermatologist.
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, and culture of any material that can be obtained from an ulcer if present. An x-ray of the teeth and jaw may be necessary also. A therapeutic trial of antibiotics or antiviral therapy can be tried. If this is unsuccessful, a referral to an oral surgeon or dermatologist should be made.
Diagnosis usually evident by history and clinical observation
–Focus on onset, duration, pain, associated symptoms (e.g., hand or foot lesions, dermatologic complaints, fever, past medical history, and exposure/sexual history)
–Physical examination should focus on the eyes, ears, nose, throat, neck, and skin, with a cursory systemic evaluation
-
For infectious causes, specific microbe identification by culture, antigen detection assays, and histologic studies is necessary, especially in immunocompromised patients
-
Laboratory evaluation may include CBC, RPR, viral titers, ESR, HIV and others
-
Chronic granulomatous disease: Lab studies may show anemia of chronic disease, leukocytosis, and elevated ESR
–Diagnosis by NBT slide test: In absence of oxidase activity, neutrophils from CGD patients do not stain with NBT dye
-
A biopsy may be necessary for definitive diagnosis; if an infectious etiology is being considered, send one part of the specimen for biopsy in formalin and a second piece in nonbacteriostatic saline for cultures
-
Consider a referral to a dermatologist, otolaryngologist, or oral surgeon in uncertain cases
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Stomatitis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Aphthous ulcers (idiopathic)
–May be due to alteration of T-cell immune function
–Triggers include dietary substances, stress, and illness
–Nutritional deficiencies (iron, B vitamins) may play a role
–May run in families, thus making it more difficult to distinguish from herpetic lesions that have been shared among family members
–May be small or large, may be singular or grouped
- Infectious stomatitis
–Coxsackievirus: Also known as hand-footand-mouth disease; all locations of lesions may not be present; usually seen in the summer and fall
–Herpetic gingivostomatitis: Common in toddlers; may last a week or longer; generally accompanied by fever, lymphadenopathy; painful lesions may cause reduction in oral intake and resultant dehydration
–Herpangina: Caused by an enterovirus rather than human herpesvirus; lesions are present primarily on the soft palate, anterior tonsillar pillars, and posterior pharynx
–Trench mouth: also known as Vincent angina; caused by fusiform bacteria or spirochetes; causes necrotizing gingivostomatitis with pseudomembrane formation; found in developing nations and malnourished patients
-
Hematologic disorders
–Associated with leukemia
–Associated with neutropenia secondary to
chemotherapy for malignancy
–Associated with cyclic neutropenia
-
Behçet disease
-
Stevens-Johnson syndrome
-
Inflammatory bowel disease: May be found in Crohn disease or ulcerative colitis
-
HIV
–Alterations in T-cell immunity can lead to aphthous ulcers
–HIV patients are more susceptible to herpetic infections
Workup and Diagnosis
-
History
–Onset, frequency, duration of symptoms
–Established or suspected triggers
–Concomitant symptom: Fever, lymphadenopathy, rash,
diarrhea, weight loss
-
Physical exam
–Size of lesions
–Distribution of lesions
–Morphologic characteristics
–Presence of other findings on physical exam: Fever,
rash, abdominal tenderness
- Labs
–Tzanck smear (shows multinucleated giant cells) or a positive herpes simplex culture can confirm herpetic gingivostomatitis
–Trench mouth may be confirmed by simple culture for fusiform bacteria or darkfield examination for spirochetes
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Mouth lesions:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.
Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.
Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Stomatitis and other oral infections:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis is based on the physical examination; in Vincent’s angina, a smear of ulcer exudate allows for identification of the causative organism.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Mouth lesions:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.
Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially any painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.
Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Stomatitis:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the oral lesion. Describe the onset: Was it abrupt, suggesting infection; or insidious, suggesting inflammatory or neoplastic origin? Are there associated signs and symptoms? Many oral infections are associated with pain, malaise, and fever. Behçet’s disease has associated ocular and genital lesions, whereas other autoimmune diseases such as systemic lupus erythematosus (SLE) or ulcerative colitis may have systemic symptoms (3). Describe the lesions: Are they painful or painless? Infections? Inflammatory lesions and aphthous ulcers are usually painful (3), whereas premalignant and malignant lesions may be painless (2,4). Are there vesicles or bullae? Pemphigoid and pemphigus can cause bullae or ulcers. HSV starts as vesicular lesions, then ulcerates. Varicella zoster lesions can occur in the mouth (3,5). Did vesicles precede the lesions, suggesting HSV, or was there ulceration without vesicles, suggesting aphthous ulcers (3)? Are the lesions white and will they not wipe off of the mucosa? Leukoplakia, a premalignant lesion, is white and will not wipe off. Any coexisting red component, called erythroplakia, greatly increases the malignant potential of the lesion (2,4). Lichen planus also produces a striated white lesion, usually on the buccal mucosa (3). Where are the lesions? HSV tends to occur on periosteally bound mucosa (gingiva, hard palate), whereas recurrent aphthous ulcers occur on nonperiosteally bound mucosa (buccal, lip, or tongue mucosa) (3). The floor of the mouth under the tongue, the lateral aspects of the tongue, the retromolar regions, and the soft palate are worrisome areas for malignancy to develop (4), but malignancy can occur anywhere.
B. Past medical history. Does the patient have systemic inflammatory conditions such as SLE or lichen planus? Has the patient had the lesions previously? Aphthous ulcers and HSV tend to recur. Does the patient wear dentures making him or her more susceptible to denture stomatitis or angular cheilitis, both caused by Candida species (5)? Are HIV-risk factors present, making oral hairy leukoplakia, Kaposi’s sarcoma, and severe oral candidiasis more likely (5)? Do family members or other close associates have similar symptoms, suggesting enteroviral infections (e.g., herpangina and hand-foot-mouth disease) (Chapter 13.3)? Is the patient on any medications known to cause oral drug-related eruptions? Sulfonamides and many other drugs can cause Stevens–Johnson syndrome, whereas recent cancer chemotherapy can produce severe mucosal inflammation.
C. Social history. Does the patient use alcohol or tobacco, thus increasing the risk for premalignancy or malignancy (2,4)? Has there been exposure to known oral irritants such as foods or spices or potential irritants such as chemicals or new mouth care products? Is the patient sexually active and has there been oral–genital contact? Syphilis and gonorrhea can both occur in the oropharynx.
Physical examination
A. Head, eyes, ears, nose, and throat (HEENT). Based on the history, a focused physical examination of the HEENT is necessary. Look for signs of trauma. Examine the conjunctiva and nasal mucosa for inflammatory changes or ulcerations. Evaluate the patient for coexisting upper respiratory signs and symptoms such as rhinorrhea, sinus tenderness to palpation, and otitis media. Inspect facial skin for vesicles from HSV or varicella-zoster or other lesions such as echymoses, malar rash, or viral exantham. Look for facial asymmetry. Varicella-zoster can cause facial nerve paralysis, called the “Ramsay Hunt syndrome.” Evaluate preauricular, postauricular, and cervical lymph node chains. Finally, evaluate the oral cavity, documenting the size, location, and appearance of the lesion.
B. Additional physical examination. Based on findings from the HEENT examination, additional physical examination might include (a) pulmonary examination for viral pneumonitis or pulmonary findings in autoimmune diseases; (b) abdominal and rectal examination for Crohn’s disease or ulcerative colitis; (c) genitourinary examination for mucosal ulcers in Behçet’s disease and Stevens–Johnson syndrome, and for signs of syphilis or gonorrhea; (d) a general skin examination looking for viral exanthemas, drug eruptions, lichen planus, pemphigus, pemphigoid, and SLE; and (e) a musculoskeletal examination for signs of SLE, Reiter’s syndrome, or other autoimmune diseases (3).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Oral Lesions:
Differential Overview
(Field Guide to Bedside Diagnosis)
Ulceration
❑ Aphthous ulcers
❑ Angular cheilitis
❑ Herpes simplex
❑ Traumatic ulcers
❑ Impetigo
❑ Erythema multiforme
❑ Mucositis
❑ Lichen planus
❑ Squamous cell cancer
❑ Syphilis
❑ Coxsackievirus A
❑ Herpes zoster
❑ Primary HIV
❑ Crohn disease
❑ Behçet syndrome
❑ Acute leukemia
❑ Pemphigoid
Glossitis
❑ Vitamin B12 deficiency
❑ Folate deficiency
❑ Niacin deficiency
❑ Riboflavin deficiency
❑ Leukoplakia
❑ Candida
❑ Geographic tongue
❑ Black hairy tongue
❑ Scarlet fever
❑ Kwashiorkor
❑ Polyarteritis nodosa
Macroglossia
❑ Myxedema
❑ Angioedema
❑ Acromegaly
❑ Amyloidosis
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Stomatitis and other oral infections:
Diagnosis
(Handbook of Diseases)
Physical examination allows diagnosis. A smear of ulcer exudate allows identification of the causative organism.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Mouth lesions:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Mouth lesions:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed odor or drainage or experienced pain. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.
Next, perform a complete oral examination, noting lesion sites and character. Examine the patient's lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums. Note any odor.
Palpate the neck for adenopathy, especially in patients who use tobacco or ingest alcohol excessively.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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