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Oral Ulceration: a Diagnostic Problem LONDON, SATURDAY 26 APRIL 1986 BRITISH Br Med J (Clin Res Ed): first published as 10.1136/bmj.292.6528.1093 on 26 April 1986. Downloaded from MEDICAL JOURNAL Oral ulceration: a diagnostic problem Most mouth ulcers are caused by trauma or are aphthous. clear, but a few patients have an identifiable and treatable Nevertheless, they may be a manifestation of a wide range of predisposing factor. Deficiency of the essential haematinics mucocutaneous or systemic disorders, including infections, -iron, folic acid, and vitamin B12-may be relevant, and the drug reactions, and disorders of the blood and gastro- possibility of chronic blood loss or malabsorption secondary intestinal systems, or they may be caused by malignant to disease in the small intestine should be excluded in these disease. The term mouth ulcers should not, therefore, be patients. Recurrent aphthous stomatitis sometimes responds used as a final diagnosis. to correction ofthe deficiency but its underlying cause should An ulcer may develop from miucosal irritation from also be sought. The ulcers may also be related to the prostheses or appliances, or from trauma such as a blow, bite, menstrual cycle in some patients and occasionally to giving or dental treatment; in such cases the diagnosis is usually up smoking.' clear from the history and from the ulcer healing rapidly in The oral ulcers of Behqet's syndrome are clinically the absence of further trauma. Failure to heal within three indistinguishable from recurrent aphthous stomatitis, but weeks raises the possibility of another diagnosis such as patients with Behqet's syndrome may also have genital malignancy. ulceration, with or without uveitis and other features of the A single persistent ulcer may result from a range ofcauses, systemic disorder.4 Mouth and genital ulceration is not but malignant disease must always be excluded. About 90% restricted to Behqet's syndrome or variants such as MAGIC of malignant neoplasms of the oral mucosa are squamous cell syndrome (mouth and genital ulcers with inflamed cartilage)' carcinomas.' These may present not only as a persistent ulcer but may also be seen in other systemic mucocutaneous or fissure or (which may may not have typical features such as disorders. There is no specific diagnostic test to establish http://www.bmj.com/ induration and a rolled edge) but also as, or associated with, Behcet's syndrome. The "pathergy test" (hyper-reactivity to white lesions (leucoplakias) or red lesions (erythroplasias). an intradermal needle prick) is said to be a useful diagnostic Any mouth ulcer that fails to resolve within three weeks after test in Japan and Turkey, but it has little value in British the removal ofan obvious local cause should be regarded with patients, who almost invariably give a negative result.6 suspicion and a biopsy specimen taken or the patient referred The features of oral ulceration associated with skin or for advice. connective tissue diseases are frequently unlike those of Most recurring mouth ulcers are due to aphthous stoma- recurrent aphthous stomatitis. There are usually several, titis. In one American series over half the healthy students more irregular and persistent large ulcers, and blisters or on 2 October 2021 by guest. Protected copyright. questioned gave a history of this,2 and the condition often desquamative gingivitis may be seen. Patients tend to be appears first in childhood or teenage life. Characteristically older than those with recurrent aphthous stomatitis, and the aphthae are painful round or ovoid ulcers; they occur most course is usually chronic. The most common skin disease to frequently on the buccal mucosa, vestibule, undersurface of have oral manifestations is lichen planus, which in the erosive the tongue, and floor of the mouth; they may be single or form may present with extensive ragged ulcers, usually on multiple, and they heal without scarring. These minor the buccal mucosa bilaterally and sometimes on the tongue. aphthae usually measure less than 5 mm in diameter and heal White lesions are often present as well, and there may be within one week to 10 days. A few patients have much larger desquamative gingivitis. Spontaneous resolution is unusual, and more persistent ulcers, which sometimes affect the and occasionally carcinoma may supervene. The auto- dorsum of the tongue or palate as well as other sites and may immune blistering diseases, such as pemphigoid and heal with scarring (major aphthae). Other patients may pemphigus, and erythema multiforme are less common develop crops of numerous painful ulcers which enlarge and but often more serious than lichen planus; the mucous coalesce to produce large ragged ulcers (herpetiform ulcers). membranes of the eyes and genitalia may be affected as well The diagnosis of recurrent aphthous stomatitis is usually as the mouth and skin. Cicatricial pemphigoid (mucous straightforward since the history and clinical appearances are membrane pemphigoid) primarily affects the oral mucosa characteristic. and causes recurring bullae and erosions, desquamative The cause of recurrent aphthous stomatitis is still not gingivitis, or both. The genitals and conjunctivae may also be © BRITISH MEDICAL JOURNAL 1986. All reproduction rights reserved. VOLUME 292 NO 6528 PAGE 1093 1094 BRITISH MEDICAL JOURNAL VOLUME 292 26 APRIL 1986 3 Rennie JS, Reade PC, Hay KD, Scully C. Recurrent aphthous stomatitis. Br DentJ 1985;159:Br Med J (Clin Res Ed): first published as 10.1136/bmj.292.6528.1093 on 26 April 1986. Downloaded from affected, and sometimes healing is associated with scar 361-7. formation. Skin lesions are infrequent in mucous membrane 4 Lehner T, Barnes CG, eds. Behkee's syndrome. London: Academic Press, 1979. 5 Firestein GS, Gruber HE, Weisman MH, Zvaifler NJ, Barber J, O'Duffy JD. pemphigoid. Similar oral lesions may be seen in other Mouth and genital ulcers with inflamed cartilage. MAGIC syndrome. AmJMed 1985;79:65-72. subepithelial disorders such as epidermolysis bulbosa, der- 6 Yazici H, Chamberlain MA, Tuzun Y, Yurdakul S, Muftuoglu A. A comparative study of the ;pathergy reaction among Turkish and British patients with Behcet's disease. Ann Rhewn Dis matitis herpetiformis, and linear IgA disease." Oral lesions 1984;43:74-5. pemphigoid, but they are seen in 7 -Scully C, Elkom M. Lichen planus: review and update on pathogenesis. J Oral Pathol 1985;14: are uncommon in bullous 431-58. most patients with pemphigus vulgaris, often preceding the 8 Williams DM, Leonard JN, Wright P, et al. Benign mucous membrane (cicatricial) pemphigoid revisited: a clinical and immnunological reappraisal. BrDensJ 1984;157:313-. appearance of skin bullae. The oral blisters of pemphigus 9 Pindborg JJ. Diseases of the skin. In: Jones JH, Mason DK, eds. Oral manifestations ofsystemic rupture early on to leave painful and persistent irregular disease. London: Saunders, 1980:318-70. 10 Grattan CEH, Small D, Kennedy CITC, Scully C. Oral herpes simplex infection in bullous erosions. pemphigoid. OralSurg 1986;61:40-3. Biopsy of the oral mucosa for conventional histological 11 Marcusen DC, Sooy CD. Otolaryngologic and head and neck manifestations of acquired immunodeficiency syndrome (AIDS). Laryngoscope 1985;95:401-5. examination and for direct immunostaining is frequently 12 Scully C, Cawson RA, eds. Oral disorders. Medicinenernational 1986;2:1129-50. needed to distinguish these mucocutaneous disorders, par- ticularly to exclude pemphigus,9 though exfolitive cytology is of little value. Erythema multiforme of the mucous membranes (Stevens-Johnson syndrome) mostly affects young men and is usually readily distinguished on clinical grounds: the presentation is often acute or recurrent, and AIDS and insects bloodstained crusting of swollen lips may be a helpful diagnostic sign. Most infective mouth ulcers are caused by viral infections A question frequently put to medical experts concerns the and are usually non-recurrent, scattered small round ulcers possibility that biting insects might play a part in the seen in a febrile child or young adult. Primary herpetic transmission of the acquired immune deficiency syndrome stomatitis is the most common viral cause of mouth ulcers. (AIDS) in Africa and elsewhere. An answer can best be It presents with scattered vesicles and ulcers and a offered by a review of the epidemiological features of the diffuse gingivitis. Recurrent intraoral herpes simplex virus disease and the epidemic in progress in central Africa. infections are rare, though they may occur in immuno- Much has been written on the transmission of lymph- compromised patients'0 including those with AIDS." Other adenopathy associated virus/human T cell lymphotropic herpes virus infections such as chickenpox and infectious virus type III (LAV/HTLV-III), the causative agent of mononucleosis may be complicated by mouth ulcers, and AIDS.`-3 The virus has been isolated repeatedly from blood, there may be unilateral mouth ulcers in zoster of the semen, and other body fluids including saliva and tears (and mandibular or maxillary divisions of the trigeminal nerve. possibly from breast milk), but there is no convincing Enteroviruses may cause mouth ulcers in herpangina and in evidence of infection in adults through any medium other hand, foot, and mouth disease. than blood or semen (and perhaps other body fluids heavily Diagnosis of these infections is primarily clinical. Viral contaminated with blood). Most cases of clinical AIDS have cultures are still the most sensitive method of diagnosing been reported from the United States, and ofa total of 15 243 infection with herpes simplex virus, though this takes from patients 73% were homosexual and bisexual men, 17% were two to four days and sometimes longer. The most rapid intravenous drug abusers, 1% were patients with haemo- philia, 2% were recipients of transfused blood or blood diagnostic technique is electron microscopy: this may take http://www.bmj.com/ only minutes to perform and is very sensitive when intact components, 1% were heterosexual sex partners of patients vesicles are examined but much less so when lesions are at a with AIDS, and the remaining 6% have not been classified by later stage.
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