Viral Diseases |
Primary acute herpetic gingivostomatitis (HSV type 1; rarely type 2) | Lip and oral mucosa (buccal, gingival, lingual mucosa) | Labial vesicles that rupture and crust, and intraoral vesicles that quickly ulcerate; extremely painful; acute gingivitis, fever, malaise, foul odor, and cervical lymphadenopathy; occurs primarily in infants, children, and young adults | Heals spontaneously in 10–14 days; unless secondarily infected, lesions lasting >3 weeks are not due to primary HSV infection |
Recurrent herpes labialis | Mucocutaneous junction of lip, perioral skin | Eruption of groups of vesicles that may coalesce, then rupture and crust; painful to pressure or spicy foods | Lasts ∼1 week, but condition may be prolonged if secondarily infected; if severe, topical or oral antiviral treatment may reduce healing time |
Recurrent intraoral herpes simplex | Palate and gingiva | Small vesicles on keratinized epithelium that rupture and coalesce; painful | Heals spontaneously in ∼1 week; if severe, topical, or oral antiviral treatment may reduce healing time |
Chickenpox (VZV) | Gingiva and oral mucosa | Skin lesions may be accompanied by small vesicles on oral mucosa that rupture to form shallow ulcers; may coalesce to form large bullous lesions that ulcerate; mucosa may have generalized erythema | Lesions heal spontaneously within 2 weeks |
Herpes zoster (VZV reactivation) | Cheek, tongue, gingiva, or palate | Unilateral vesicular eruptions and ulceration in linear pattern following sensory distribution of trigeminal nerve or one of its branches | Gradual healing without scarring unless secondarily infected; postherpetic neuralgia is common; oral acyclovir, famciclovir, or valacyclovir reduces healing time and postherpetic neuralgia |
Infectious mononucleosis (Epstein-Barr virus) | Oral mucosa | Fatigue, sore throat, malaise, fever, and cervical lymphadenopathy; numerous small ulcers usually appear several days before lymphadenopathy; gingival bleeding and multiple petechiae at junction of hard and soft palates | Oral lesions disappear during convalescence; no treatment is given, though glucocorticoids are indicated if tonsillar swelling compromises the airway |
Herpangina (coxsackievirus A; also possibly coxsackievirus B and echovirus) | Oral mucosa, pharynx, tongue | Sudden onset of fever, sore throat, and oropharyngeal vesicles, usually in children <4 years old, during summer months; diffuse pharyngeal congestion and vesicles (1–2 mm), grayish-white surrounded by red areola; vesicles enlarge and ulcerate | Incubation period of 2–9 days; fever for 1–4 days; recovery uneventful |
Hand-foot-and-mouth disease (most commonly coxsackievirus A16) | Oral mucosa, pharynx, palms, and soles | Fever, malaise, headache with oropharyngeal vesicles that become painful, shallow ulcers; highly infectious; usually affects children under age 10 | Incubation period 2–18 days; lesions heal spontaneously in 2–4 weeks |
Primary HIV infection | Gingiva, palate, and pharynx | Acute gingivitis and oropharyngeal ulceration, associated with febrile illness resembling mononucleosis and including lymphadenopathy | Followed by HIV seroconversion, asymptomatic HIV infection, and usually ultimately by HIV disease |
Bacterial or Fungal Diseases |
Acute necrotizing ulcerative gingivitis (“trench mouth”) | Gingiva | Painful, bleeding gingiva characterized by necrosis and ulceration of gingival papillae and margins plus lymphadenopathy and foul breath | Debridement and diluted (1:3) peroxide lavage provide relief within 24 h; antibiotics in acutely ill patients; relapse may occur |
Prenatal (congenital) syphilis | Palate, jaws, tongue, and teeth | Gummatous involvement of palate, jaws, and facial bones; Hutchinson’s incisors, mulberry molars, glossitis, mucous patches, and fissures at corner of mouth | Tooth deformities in permanent dentition irreversible |
Primary syphilis (chancre) | Lesion appearing where organism enters body; may occur on lips, tongue, or tonsillar area | Small papule developing rapidly into a large, painless ulcer with indurated border; unilateral lymphadenopathy; chancre and lymph nodes containing spirochetes; serologic tests positive by third to fourth weeks | Healing of chancre in 1–2 months, followed by secondary syphilis in 6–8 weeks |
Secondary syphilis | Oral mucosa frequently involved with mucous patches, which occur primarily on palate and also at commissures of mouth | Maculopapular lesions of oral mucosa, 5–10 mm in diameter with central ulceration covered by grayish membrane; eruptions occurring on various mucosal surfaces and skin, accompanied by fever, malaise, and sore throat | Lesions may persist from several weeks to a year |
Tertiary syphilis | Palate and tongue | Gummatous infiltration of palate or tongue followed by ulceration and fibrosis; atrophy of tongue papillae produces characteristic bald tongue and glossitis | Gumma may destroy palate, causing complete perforation |
Gonorrhea | Lesions may occur in mouth at site of inoculation or secondarily by hematogenous spread from a primary focus | Most pharyngeal infection is asymptomatic; may produce burning or itching sensation; oropharynx and tonsils may be ulcerated and erythematous; saliva viscous and fetid | More difficult to eradicate than urogenital infection, though pharyngitis usually resolves with appropriate antimicrobial treatment |
Tuberculosis | Tongue, tonsillar area, soft palate | Painless, solitary, 1- to 5-cm, irregular ulcer covered with persistent exudate; ulcer has firm undermined border | Autoinoculation from pulmonary infection is usual; lesions resolve with appropriate antimicrobial therapy |
Cervicofacial actinomycosis | Swellings in region of face, neck, and floor of mouth | Infection may be associated with extraction, jaw fracture, or eruption of molar tooth; in acute form, resembles acute pyogenic abscess, but contains yellow “sulfur granules” (gram-positive mycelia and their hyphae) | Typically, swelling is hard and grows painlessly; multiple abscesses with draining tracts develop; penicillin first choice; surgery usually necessary |
Histoplasmosis | Any area of the mouth, particularly tongue, gingiva, or palate | Nodular, verrucous, or granulomatous lesions; ulcers are indurated and painful; usual source hematogenous or pulmonary, but may be primary | Systemic antifungal therapy necessary |
Candidiasisa | | | |
Dermatologic Diseases |
Mucous membrane pemphigoid | Typically produces marked gingival erythema and ulceration; other areas of oral cavity, esophagus, and vagina may be affected | Painful, grayish-white collapsed vesicles or bullae of full-thickness epithelium with peripheral erythematous zone; gingival lesions desquamate, leaving ulcerated area | Protracted course with remissions and exacerbations; involvement of different sites develops slowly; glucocorticoids may temporarily reduce symptoms but do not control disease |
EM minor and EM major (Stevens-Johnson syndrome) | Primarily oral mucosa and skin of hands and feet | Intraoral ruptured bullae surrounded by inflammatory area; lips may show hemorrhagic crusts; “iris” or “target” lesion on skin is pathognomonic; patient may have severe signs of toxicity | Onset very rapid; usually idiopathic, but may be associated with trigger such as drug reaction; condition may last 3–6 weeks; mortality rate for untreated EM major is 5–15% |
Pemphigus vulgaris | Oral mucosa and skin; sites of mechanical trauma (soft/hard palate, frenulum, lips, buccal mucosa) | Usually (>70%) presents with oral lesions; fragile, ruptured bullae and ulcerated oral areas; mostly in older adults | With repeated occurrence of bullae, toxicity may lead to cachexia, infection, and death within 2 years; often controllable with oral glucocorticoids |
Lichen planus | Oral mucosa and skin | White striae in mouth; purplish nodules on skin at sites of friction; occasionally causes oral mucosal ulcers and erosive gingivitis | White striae alone usually asymptomatic; erosive lesions often difficult to treat, but may respond to glucocorticoids |
Other Conditions |
Recurrent aphthous ulcers | Usually on nonkeratinized oral mucosa (buccal and labial mucosa, floor of mouth, soft palate, lateral and ventral tongue) | Single or clustered painful ulcers with surrounding erythematous border; lesions may be 1–2 mm in diameter in crops (herpetiform), 1–5 mm (minor), or 5–15 mm (major) | Lesions heal in 1–2 weeks but may recur monthly or several times a year; protective barrier with benzocaine and topical glucocorticoids relieve symptoms; systemic glucocorticoids may be needed in severe cases |
Behçet’s syndrome | Oral mucosa, eyes, genitalia, gut, and CNS | Multiple aphthous ulcers in mouth; inflammatory ocular changes, ulcerative lesions on genitalia; inflammatory bowel disease and CNS disease | Oral lesions often first manifestation; persist several weeks and heal without scarring |
Traumatic ulcers | Anywhere on oral mucosa; dentures frequently responsible for ulcers in vestibule | Localized, discrete ulcerated lesions with red border; produced by accidental biting of mucosa, penetration by foreign object, or chronic irritation by dentures | Lesions usually heal in 7–10 days when irritant is removed, unless secondarily infected |
Squamous cell carcinoma | Any area of mouth, most commonly on lower lip, lateral borders of tongue, and floor of mouth | Red, white, or red and white ulcer with elevated or indurated border; failure to heal; pain not prominent in early lesions | Invades and destroys underlying tissues; frequently metastasizes to regional lymph nodes |
Acute myeloid leukemia (usually monocytic) | Gingiva | Gingival swelling and superficial ulceration followed by hyperplasia of gingiva with extensive necrosis and hemorrhage; deep ulcers may occur elsewhere on mucosa, complicated by secondary infection | Usually responds to systemic treatment of leukemia; occasionally requires local irradiation |
Lymphoma | Gingiva, tongue, palate, and tonsillar area | Elevated, ulcerated area that may proliferate rapidly, giving appearance of traumatic inflammation | Fatal if untreated; may indicate underlying HIV infection |
Chemical or thermal burns | Any area in mouth | White slough due to contact with corrosive agents (e.g., aspirin, hot cheese) applied locally; removal of slough leaves raw, painful surface | Lesion heals in several weeks if not secondarily infected |