Mouth lesions
Mouth lesions include ulcers (the most common type), cysts, firm nodules, hemorrhagic lesions, papules, vesicles, bullae, and erythematous lesions. They may occur anywhere on the lips, cheeks, hard and soft palate, salivary glands, tongue, gingivae, or mucous membranes. Many are painful and can be readily detected. Some, however, are asymptomatic; when they occur deep in the mouth, they may be discovered only through a complete oral examination. (See Common mouth lesions.)
Mouth lesions can result from trauma, infection, systemic disease, drug use, or radiation therapy.
History and physical examination
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.
Medical causes
Acquired immunodeficiency syndrome (AIDS)
Oral lesions may be an early indication of the immunosuppression that’s characteristic of this disease. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of oral mucosa, tongue, gingivae, and periodontal tissue may also occur.
The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.
Actinomycosis (cervicofacial)
This chronic fungal infection typically produces small, firm, flat, usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.
Behçet’s syndrome
This chronic, progressive syndrome that generally affects young males produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.
Candidiasis
This common fungal infection characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and foul odor may be present.
Discoid lupus erythematosus
Oral lesions are common, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.
Gender Cue: This chronic, recurrent disease is most common in women ages 30 to 40.
Epulis (giant cell)
This rare tumor or growth occurs on the gingival or alveolar process, anterior to the molars. Dark red, pedunculated or sessile, and 0.5 to 1.5 cm in diameter, it commonly ulcerates to produce a concave defect in the underlying bone. Gingivae bleed easily with slight trauma.
Erythema multiforme
This acute inflammatory skin disease produces sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgias, arthralgias, fingernail loss, blindness, hematuria, and signs of renal failure.
Gingivitis (acute necrotizing ulcerative)
This recurring periodontal condition causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.
Gonorrhea
Painful lip ulcerations may occur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated tongue. Related effects vary. Most men develop dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.
Herpes simplex 1
With primary infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.
Herpes zoster
This common viral infection may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules often erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.
Inflammatory fibrous hyperplasia
This painless nodular swelling of the buccal mucosa typically results from cheek trauma or irritation and is characterized by pink, smooth, pedunculated areas of soft tissue.
Leukoplakia, erythroplakia
Leukoplakia is a white lesion that cannot be removed simply by rubbing the mucosal surface—unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.
Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.
Lichen planus
Oral lesions develop on the buccal mucosa or, less commonly, on the tongue as painless, white or gray, velvety, threadlike papules. These precede the eruption of violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus; nails with longitudinal ridges; and alopecia.
Mucous duct obstruction
Obstruction produces a ranula—a painless, slow-growing mucocele on the floor of the mouth near the ducts of the submandibular and sublingual glands.
Pemphigoid (benign mucosal)
This rare autoimmune disease is characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less often, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.
Pemphigus
This chronic skin disease is characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.
Pyogenic granuloma
Commonly the result of injury, trauma, or irritation, this soft, tender nodule, papule, or polypoid mass of excessive granulation tissue usually appears on the gingivae but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.
Squamous cell carcinoma
This is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or the floor of the mouth. High risk factors include chronic smoking and alcohol intake.
Stomatitis (aphthous)
This common disease is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.
With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.
With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.
Syphilis
Primary syphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.
During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, low fever, metrorrhagia, and postcoital bleeding.
At the tertiarystage, lesions (often chronic, painless, superficial nodules or deep granulomatous lesions, called gummas) develop on the skin and mucous membranes, especially the tongue and palate.
Systemic lupus erythematosus
Oral lesions are common and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, butterfly rash across the nose and cheeks, and photosensitivity.
Trauma
The most common cause of oral lesions, trauma can produce ulcers anywhere in the mouth, especially on the tongue and buccal mucosa.
Tuberculosis (oral mucosal)
This rare disorder produces a painless ulcer (usually on the tongue) and, sometimes, caseation. Other findings include lymphadenopathy, fatigue, weakness, anorexia, weight loss, cough, low fever, and night sweats.
Other causes
Drugs
Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.
Orthodontics
The rubbing of orthodontic equipment or prosthesis on the buccal mucosa may cause eroded, tender areas.
Radiation therapy
Radiation therapy may cause oral lesions.
Special considerations
If the patient’s mouth ulcers are painful, provide a topical anesthetic such as lidocaine.
Pediatric pointers
Causes of mouth ulcers in children include chickenpox, measles, scarlet fever, diphtheria, and hand-foot-and-mouth disease. In neonates, mouth ulcers can result from candidiasis or congenital syphilis.
Patient counseling
Instruct the patient to avoid irritants, such as highly seasoned foods, citrus fruits, foods that contain salt or vinegar, alcohol, and tobacco. For mouth care, warn against using lemon-glycerin swabs because these can dry and irritate the lesions.
As appropriate, teach the patient proper oral hygiene. If toothbrushing is contraindicated, instruct him to use a mouth rinse, such as normal saline solution or half-strength hydrogen peroxide, and to avoid commercial mouthwashes that contain alcohol. Stress the importance of frequently changing to a new toothbrush. If the patient uses an inhaled steroid, instruct him to rinse his mouth after each use. Also, tell him to report mouth lesions that don’t heal within 2 weeks.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Oral pain
» Next page: Oral Lesions (Field Guide to Bedside Diagnosis)
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