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, don’t produce symptoms; 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
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.
Physical assessment
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; especially note 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
Oral lesions may be an early indication of the immunosuppression that’s characteristic of acquired immunodeficiency syndrome (AIDS). 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. Initially producing no symptoms, it may appear as a flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.
Candidiasis
Candidiasis, a 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 in discoid lupus erythematosus. They typically appear 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.
Erythema multiforme
Erythema multiforme, an 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, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.
Gingivitis (acute necrotizing ulcerative)
Gingivitis, a 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
With 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 herpes simplex 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
Herpes zoster is a common viral infection that may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small, red nodules usually 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.
Leukoplakia, erythroplakia
Leukoplakia is a white lesion that can’t 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 erythroplakia cases are either dysplasia or cancer.
Lichen planus
With 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.
Squamous cell carcinoma
A squamous cell carcinoma 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)
Aphthous stomatitis is a common disease 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
Primarysyphilis 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 (usually gummas — chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.
Systemic lupus erythematosus
Oral lesions are common with systemic lupus erythematosus (SLE) 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.
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.
Treatments
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.
Geriatric pointers
Ill-fitting dentures can cause irritation, leading to inflammation and ulcers (inflammatory fibrous hyperplasia).
Patient counseling
Instruct the patient to avoid irritants, such as highly seasoned foods, citrus fruits, alcohol, tobacco, and foods that contain salt or vinegar. 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 any mouth lesions that don’t heal within 2 weeks.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Red tongue
Read excerpts from these other book chapters related to Red tongue:
Medical Books Excerpts
- Mouth lesions
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Stomatitis
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Red tongue
» Next page: Mouth lesions (Nursing: Interpreting Signs and Symptoms)
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