Oral maladies examined

July 1, 2007

Mucosal vesiculation, blistering and ulceration can have many different etiologies. Identifying the lesion is simple, but getting to the bottom of the cause may be a bit more difficult. One expert reviews the spectrum of mucosal ulcerations and their treatments.

Key Points

Rochester, Minn. - Diagnosing vesicles, blisters and ulcerations in and around the oral mucosa may be relatively straightforward, but finding the cause of these lesions can sometimes prove to be challenging.

"Oral ulcers are distinguished as acute, lasting less than six weeks, and chronic, lasting longer than six weeks. Acute oral ulcers are further subdivided into either recurrent or single-episode ulcers, and may be associated with other symptoms that are telltale of the diagnosis," says Alison J. Bruce, M.B.Ch.B., of the department of dermatology at the Mayo Clinic.

Acute etiologies

"Primary herpes simplex virus infection is a common cause of acute oral ulcerations, found typically on both the masticatory and soft mucosal tissue. Children are more commonly affected than adults and present with fever, malaise and lymphadenopathy," Dr. Bruce tells Dermatology Times.

Dr. Bruce says that supportive therapies for viral infections include cold fluids (ice chips, popsicles), antipyretics and analgesics (e.g., acetaminophen), as well as maintenance of oral hygiene with hydrogen peroxide 1 percent as a mouthwash. Palliative therapies for viral infections can include coating agents such as aluminum and topical anesthetic dental pastes. She says that depending on the symptoms and intensity of the infection, antivirals such as acyclovir, famciclovir or valacyclovir can also be given orally or intravenously.

Dr. Bruce says trauma, recurrent aphthous stomatitis and intraoral herpes simplex stomatitis can also cause recurrent acute oral ulcerations.

Managing multiple faces of aphthosis

"Topical antiviral therapies for treating recurrent herpes labialis, such as over-the-counter (OTC) and docosanol 10 percent cream (Pfizer), can be used to treat recurrent lesions.

"These are efficacious in decreasing the time to healing as well as the duration of the symptoms," Dr. Bruce says.

Dr. Bruce explains that there is evidence for cell-mediated immunopathogenesis in recurrent aphthous stomatitis (RAS) and that the lesions of RAS are the mucosal manifestations of a variety of diseases. According to Dr. Bruce, a recurrent aphthous stomatitis can be classified as either simple or complex, as well as minor, major or herpetiform in its morphology.

"The vast majority of sufferers of RAS have simple aphthosis and these patients with RAS present with intermittent, mild and infrequent episodes of canker sores. Patients with a complex aphthosis, on the other hand, may present with recurrent oral and genital aphthous ulcers or almost constant, multiple oral aphthae, in the absence of Behcet's disease," Dr. Bruce says.

She adds that aphthosis is a multifactorial disease and that there are several subsets of aphthosis. It can be associated with a slew of diseases, including ulcus vulvae acutum, aphthous stomatitis et vulvitis, chronic ulcerative colitis, Crohn's disease, gluten-sensitive enteropathy, MAGIC syndrome (mouth and genital ulcers with inflamed cartilage), FAPA syndrome (fever, aphthosis, pharyngitis and adenitis) and AIDS, as well as IgA deficiency.

According to Dr. Bruce, complex aphthosis can be associated with numerous conditions, including anemia and/or hematinic deficiencies, GI diseases, hematopoietic and/or immunodeficiency, smoking cessation, drug reactions, trauma, pseudo-Behcet's disease and RAS-associated erythema multiforme.

"Many patients with complex aphthosis have recognizable underlying conditions, some of which are amenable to treatment. The clinician should seek 'correctable causes' and associated conditions in all patients with complex aphthosis. This means that deficiencies should be identified and replaced, treating primary diseases such as Crohn's disease, modifying provocative factors such as drug reactions and trauma and treat with corticosteroids and nonsteroidal anti-inflammatory drugs, such as colchicines and/or dapsone, among others," Dr. Bruce says.

Simple aphthosis can be treated topically with corticosteroids, silver nitrate, Debacterol and topical anesthetics. Patients should be careful to reduce oral trauma and practice careful oral hygiene.

"Understanding the immunological basis of aphthosis provides a rationale for therapy. Also, the recognition of the associated diseases provides more treatment options," Dr. Bruce says.

Disclosures: Dr. Bruce reports no relevant financial disclosures.