Oral Lesions
Oral Lesions: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
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
Clinical Findings
Aphthous ulcers They occur on nonkeratinized mucosa as single lesions or clusters of small, shallow, painful, clearly defined ulcers with an erythematous halo and a white base. There are usually no systemic symptoms or lymphadenopathy. These ulcers stereotypically recur.
Angular cheilitis Tender fissuring at the corner of the mouth can be caused by Candida and either iron or vitamin B12 deficiency.
Herpes simplex An acute outbreak consists of labial vesicles that rupture and crust, and intraoral vesicles that quickly ulcerate. The lesions are usually quite painful and associated with fever, malaise, pharyngitis, and tender cervical lymphadenopathy. Recurrent lesions usually occur at the vermilion border and are preceded by localized burning dysesthesias.
Traumatic ulcers These ulcers occur at the bite margin or adjacent to dentures.
Impetigo Perioral painful shallow erosions spread rapidly. They are red and weeping, with honey-colored crusts.
Erythema multiforme The onset is rapid and progresses to systemic toxicity. Intraoral ruptured bullae surrounded by erythema become painful mucosal erosions with gray exudate. Hemorrhagic crusts appear on the lips. An extensive maculopapular rash develops on the extensor surfaces and is characterized by target and polycyclic lesions and persisting urticarial plaques. Target lesions on the hands and feet are pathognomonic.
Mucositis Initially there is a burning with diffuse mucosal redness and shininess that progresses to painful ulcers, then the tongue and buccal mucosa become denuded. There may also be a yellow pseudomembrane or hemorrhagic crust. This condition is found with Stevens-Johnson syndrome, agranulocytosis, and cancer chemotherapy.
Lichen planus Lacy mucosal striae break down into painful erosions. This is often associated with drugs such as chloroquine, furosemide, gold, lithium, methyldopa, phenothiazines, propranolol, quinidine, spironolactone, tetracycline, or thiazides.
Squamous cell cancer The ulcer is painless, malodorous, and indolent. It arises in an area of leukoplakia, bleeds easily, and has an elevated, indurated border. The presenting symptom is often pain, which may be referred to the ear, or dysphonia.
Syphilis A primary chancre is a painless ulcer with an indurated copper border and unilateral lymphadenopathy. Secondary lesions are linear “snail track” ulcers and gray mucous patches on the lips, tonsils, and palate. There is concurrent generalized rash and fever. A tertiary gumma is a firm, broad, ulcerated plaque that may produce palatal perforation.
Coxsackievirus A Herpangina presents with fever, sore throat, and grayish-white vesicles with a red halo, which quickly ulcerate. Hand, foot, and mouth disease (A16) has similar pharyngeal lesions accompanied by other lesions in the forenamed distribution.
Herpes zoster A vesicular eruption with ulceration stops at the midline. Vesicles will also be present on the lower midface. Burning pain is characteristic.
Primary HIV The most common presentation is a febrile mononucleosislike illness. Acute gingivitis and ulceration may be part of the spectrum.
Crohn disease Oral ulcers may occur when intestinal disease is active, with symptoms of diarrhea, mucus, and blood.
Behçet syndrome Multiple aphthous ulcers of the mouth occur with uveitis and genital ulcers.
Acute leukemia Gingival swelling and superficial ulceration occur; hyperplasia, hemorrhage, and necrosis ensue. Deep ulcers may occur elsewhere on the mucosa, and they often become secondarily infected.
Pemphigoid Painful grayish-white collapsed vesicles or bullae ulcerate when on the gingiva. Bullae may also involve the eyes, urethra, vagina, or rectum.
Vitamin B12 deficiency The tongue is beefy red, smooth, edematous, and painful. Pinpoint dots occur as a result of hyperemic capillaries and atrophied papillae. Peripheral neuropathy is commonly concurrent.
Folate deficiency It is similar in presentation to B12 deficiency but occurs more rapidly with nutritional depletion (e.g., alcoholics).
Niacin deficiency Pellagra produces a burning sensation with hot or spicy food, without a visible abnormality early in the course. Later there is an increase in papilla and redness of the tongue’s tip and sides, and then fiery redness and swelling with desquamation occur. It is associated with severe watery diarrhea, red skin eruptions, and confusion.
Riboflavin deficiency When advanced, the tongue looks magenta. Associated findings include a “shark skin” nose and conjunctival injection.
Leukoplakia Early lesions are thin, pearly, and crinkled, especially on the lateral border of the tongue. A white-gray thickened epithelium without papillae appears later. Oral hairy leukoplakia is a sentinel finding of HIV infection, and is caused by concurrent EBV infection.
Candida The tongue is bright red with cottage cheese-like material on the surface. Predisposing conditions include diabetes, dentures, recent antibiotics, or chemotherapy. In the absence of these factors, or severe or recalcitrant disease, HIV should be considered.
Geographic tongue The surface has a changing demarcated pattern. There may be oral discomfort or burning. This finding is present in serious illness with antibiotic use.
Black hairy tongue Elongated filiform papillae which may be discolored a yellow to brownish tone create the appearance. Associated conditions include antibiotic use, oral candidiasis, and poor oral hygeine.
Scarlet fever A “strawberry tongue” occurs in a patient with a confluent rash that has the texture of fine sandpaper.
Kwashiorkor Glossitis occurs early and is later accompanied by generalized edema and ascites.
Polyarteritis nodosa The patient presents with a diffusely inflamed, orange-red tongue that has a burning sensation.
Myxedema In addition to tongue enlargement, facial and pretibial skin is coarse, the voice is low and husky, and the relaxation phase of the deep tendon reflexes is delayed.
Angioedema Acute edema of tissues frequently includes the tongue. Similar findings may occur with food allergies (e.g., shellfish), drug reactions (penicillin), and serum sickness.
Acromegaly Tissues are generally thickened, and tongue enlargement is associated with jaw protrusion, malocclusion, and teeth that are widely spaced and tilt outward.
Amyloidosis Tongue enlargement occurs with enlargement of other viscera and with peripheral neuropathy.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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