Common Lesions of the Oral Soft Tissues

Oropharyngeal Candidiasis

Oropharyngeal infection with Candida albicans (thrush, moniliasis) (see Chapter 261.1 ) is common in neonates from contact with the organism in the birth canal or contact with the breast during breastfeeding. The lesions of oropharyngeal candidiasis (OPC) appear as white plaques covering all or part of the oropharyngeal mucosa. These plaques are removable from the underlying surface, which is characteristically inflamed and has pinpoint hemorrhages. The diagnosis is confirmed by direct microscopic examination on potassium hydroxide smears and culture of scrapings from lesions. OPC is usually self-limited in the healthy newborn infant, but topical application of nystatin to the oral cavity of the baby and to the nipples of breastfeeding mothers will hasten recovery.

OPC is also a major problem during myelosuppressive therapy. Systemic candidiasis , a major cause of morbidity and mortality during myelosuppressive therapy, develops almost exclusively in patients who have had prior oropharyngeal, esophageal, or intestinal candidiasis. This observation implies that prevention of OPC should reduce the incidence of systemic candidiasis. The use of oral rinses of 0.2% chlorhexidine gluconate solution along with systemic antifungals may be effective in preventing OPC, systemic candidiasis, or candidal esophagitis.

Aphthous Ulcers

The aphthous ulcer (canker sore) is a distinct oral lesion ( Fig. 341.1 ), prone to recurrence; Table 341.1 notes the differential diagnosis. Aphthous ulcers are reported to develop in 20% of the population. Their etiology is unclear, but allergic or immunologic reactions, emotional stress, genetics, and injury to the soft tissues in the mouth have been implicated. Aphthous-like lesions may be associated with inflammatory bowel disease, Behçet disease, gluten-sensitive enteropathy, periodic fever-aphthae-pharyngitis-adenitis syndrome, Sweet syndrome, HIV infection (especially if ulcers are large and slow to heal), and cyclic neutropenia. Clinically, these ulcers are characterized by well-circumscribed, ulcerative lesions with a white necrotic base surrounded by a red halo. The lesions generally last 10-14 days and heal without scarring. Nonprescription palliative therapies, such as benzocaine and topical lidocaine, are effective, as are topical steroids. Tetracycline has benefit with severe outbreaks, but caution is necessary in pregnant women, since it is classified as FDA pregnancy category D. In younger children (≤8 yr), tetracycline can affect developing teeth and cause permanent staining of the teeth.

Herpetic Gingivostomatitis

After an initial incubation period of approximately 1 wk, the primary infection with herpes simplex virus manifests as fever and malaise, usually in a child younger than 5 yr (see Chapter 279 ). The oral cavity can show various expressions, including the gingiva becoming erythematous, mucosal hemorrhages, and clusters of small vesicles erupting throughout the mouth. There is often involvement of the mucocutaneous margin and perioral skin ( Fig. 341.2 ). The oral symptoms generally are accompanied by fever, lymphadenopathy, and difficulty eating and drinking. The symptoms usually regress within 2 wk without scarring. Fluids should be encouraged because the child may become dehydrated. Analgesics and anesthetic rinses can make the child more comfortable. Oral acyclovir, if taken within the first 3 days of symptoms in immunocompetent patients, is beneficial in shortening the duration of symptoms. Caution should be exercised to prevent autoinoculation, especially of the eyes.

Recurrent Herpes Labialis

Approximately 90% of the worldwide population develops antibodies to herpes simplex virus. In periods of quiescence, the virus is thought to remain latent in sensory neurons. Unlike primary herpetic gingivostomatitis which manifests as multiple painful vesicles on the lips, tongue, palate, gingiva, and mucosa, recurrent herpes is generally limited to the lips. Other than the annoyance of causing pain and being a cosmetic issue, recurrent episodes generally do not involve systemic symptoms. Reactivation of the virus is thought to be the result of exposure to ultraviolet light, tissue trauma, stress, or fevers. There is little advantage of antiviral therapy over palliative therapies in an otherwise healthy patient affected by recurrent herpes.