Chapter 1 SORE MOUTH

KEY POINTS

• The commonest fungal infection in the mouth is Candida albicans. Always look for a predisposing factor (systemic disease, drugs, diabetes or HIV infection).

• In gingivitis, a red line limited to the entire gingival margin (linear gingival erythema) can be a marker of HIV infection.

• Recurrent aphthous ulcers tend to start in childhood or adolescence, and heal spontaneously in 2–10 days. The cause is unknown. Major aphthae are more severe and can persist for months, healing by scar formation.

• Gastrointestinal causes of oral ulceration include coeliac disease, Crohn’s disease and ulcerative colitis.

• The bullous eruption of pemphigus (usually pemphigus vulgaris) may be restricted to the mouth before a skin rash appears.

• Mucous membrane pemphigoid selectively involves the mucosa lining the mouth, conjunctiva, pharynx, oesophagus, larynx and vagina. Skin lesions are uncommon.

• A minority of leucoplakias are potentially malignant.

• More than 90% of oral malignancies are squamous cell carcinomas.

• Do not confuse the burning mouth syndrome with heartburn.

EXAMINATION OF THE MOUTH

Wear gloves, a mask and spectacles or goggles for oral examinations.

Extraoral

Is there any facial swelling, asymmetry or altered cutaneous sensation? Are the submandibular and other cervical lymph nodes palpable?

Intraoral

Ask the patient to open their mouth wide. Normally finger breadths can be inserted between upper and lower incisors.

Does the patient’s breath have an offensive odour (halitosis) due to gum disorders (periodontitis), alcohol or tobacco, ketones in untreated or poorly managed diabetes (predominantly type 1) or due to liver failure?

A good light source is very helpful. If available, a head-light or a dentist’s light are ideal rather than a battery pencil torch. A pair of dental mirrors helps to both retract the lips, cheeks and tongue and illuminate the mouth. A gauze square is essential to hold (gently) and retract the tongue to inspect the floor of the mouth and ventral surface and lateral margins of the tongue, relatively common sites for precancerous growths and cancers. Subtle changes are best detected by drying the oral mucosa with a gauze square (or air syringe, if available).

Examine each part of the mouth in turn: vermilion margin and inner mucosal surface of lips, buccal mucosa, retromolar trigone, gingivae, the lateral margins, ventral surface, dorsum and base of tongue and hard and soft palate. Note any grossly decayed, loose or discoloured teeth. This systematic approach ensures that small lesions will not be overlooked. Inflammation of the palate covered by dentures is usually due to Candida (denture stomatitis). Ask the patient to remove any dentures and assess their cleanliness. Note whether they are old, unstable or ill fitting.

CAUSES OF SORE MOUTH

The causes of sore mouth are listed in Table 1.1.

TABLE 1.1 Causes of sore mouth

Trauma	Gastrointestinal Coeliac disease Crohn’s disease Ulcerative colitis
Infection Bacterial Dental Tuberculosis Syphilis Fungal Candida Viral Herpes simplex (HSV-1 & 2) Herpes zoster (varicella zoster, HHV-3) Cytomegalovirus (HHV-5) Hand-foot-mouth disease (coxsackievirus) Herpangina	Bullous or erosive Pemphigus Cicatrising mucous membrane pemphigoid Erythema multiforme Systemic lupus erythematosus
	Potentially malignant Leucoplakia Lichen planus Lichenoid reactions – drugs – graft-versus-host disease – amalgam fillings Discoid lupus erythematosus Oral submucous fibrosis
Idiopathic Aphthous ulceration Geographical tongue ACE inhibitors (scalded mouth sensation) Sarcoidosis	Xerostomia Sjögren’s syndrome Drugs: antihypertensive, diuretic Radiotherapy
Haematological Anaemias: iron, vitamin B12, folate deficiency Neutropenias Leukaemias	Malignant Squamous cell carcinoma Kaposi’s sarcoma Non-Hodgkin’s lymphoma

Infections

Fungal infections

These are usually due to Candida. Thrush (acute pseudomembranous candidiasis), usually due to Candida albicans, is a relatively common cause of sore mouth. The diagnosis can usually be made clinically from the scattered white plaques resembling clotted milk that are easily wiped off the oral mucosa, leaving a red base. If doubt remains, laboratory confirmation is available by microscopy and culture of a swab. Always look for predisposing factors. Systemic causes include pharmacotherapy with immunosuppressive drugs, steroids, cytotoxic therapy, or antibiotics, as well as human immunodeficiency virus (HIV) infection, particularly before HAART begins, and diabetes.

Management

Topical antifungals, amphotericin B 10 mg lozenges three times daily for 1 week, dissolved slowly in mouth or nystatin pastilles 100,000 units or lozenges 500,000 units, allowed to dissolve in mouth or as a suspension 100,000 units/mL four times daily for 1 week. In immunocompromised states, oral itraconazole (contraindicated in acute hepatitis) 100–200 mg daily for 1 week may be needed.

Denture stomatitis

This appears as a fiery, red inflammation of the palate under the upper dentures and is a chronic form of Candida infection associated with the habit of continuous day and night wearing of dentures and poor hygiene. A candidal angular stomatitis (angular cheilitis) at the corners of the mouth may result. Advise the patient to clean the dentures with a brush and to leave them out at night in a 1% sodium hypochlorite disinfectant solution (e.g. Milton), and prescribe topical amphotericin B 10 mg lozenges three times daily for 1 week.

Median rhomboid glossitis

Median rhomboid glossitis is a red area of papillary atrophy in the midline of the posterior third of the tongue. It may remain asymptomatic or cause occasional soreness. It appears to be a chronic acquired oral candidiasis and not a developmental anomaly as previously supposed. Predisposing factors include tobacco smoking, continuous night and day denture wearing and steroid sprays for asthma or HIV infection. The condition is quite harmless and management involves attending to predisposing factors and topical amphotericin B 10 mg lozenges three times daily for 1 week to alleviate soreness.

Viral infections

Herpes simplex (human herpes virus type 1, less commonly 2)

Oral herpes simplex infections usually present in young children with fever, malaise, enlarged tender submandibular lymph nodes, widespread small irregular mouth ‘ulcers’ and swollen inflamed gums (often dismissed as ‘teething’). The diagnosis can usually be made clinically, but laboratory tests include a smear for microscopy, swab for culture or direct immunofluorescence of a saline mouth rinse and a blood sample to show an immediate rise in IgM antibody. Aqueous 0.2% chlorhexidine mouth baths or, for the immunocompromised, aciclovir 400 mg five times daily for 5 days or famciclovir for aciclovir-resistant infections. Recurrent herpes simplex infections are usually restricted to the lips (herpes labialis or ‘cold sores’), and only rarely affect the oral cavity, which may be involved, however, where HSV is reactivated in immunocompromised states. Early application of 5% aciclovir or penciclovir cream is useful for treating cold sores.

Varicella zoster virus (human herpes virus 3)

Patients with varicella zoster virus infections are usually middle aged or elderly. After prodromal symptoms of facial pain and fever, vesicles appear on the face or as ulcers in the mouth in a unilateral distribution corresponding to one or more divisions of the trigeminal nerve (V2 or V3, less often V1). Chlorhexidine mouth baths and famciclovir 500 mg three times daily for 7 days speeds healing and also reduces the likelihood of post-herpetic neuralgia. Don’t forget that this reactivation of human herpes virus 3 may be a marker of malignancy (e.g. lymphoma) or immunosuppression.

Cytomegalovirus (human herpes virus 5)

Infections may uncommonly present as mouth ulceration due to reactivation in immunosuppressed states or, rarely, as a parotitis.

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