Intraoral ulcerations of recurrent herpes simplex and recurrent aphthae: two distinct clinical entities

Ulcerated Lesions of the Oral Mucosa: Clinical and Histologic Review

Ulcerated lesions of the oral cavity have many underlying etiologic factors, most commonly infection, immune related, traumatic, or neoplastic. A detailed patient history is critical in assessing ulcerative oral lesions and should include a complete medical and medication history; whether an inciting or triggering trauma, condition, or medication can be identified; the length of time the lesion has been present; the frequency of episodes in recurrent cases; the presence or absence of pain; and the growth of the lesion over time. For multiple or recurrent lesions the presence or history of ulcers on the skin, genital areas, or eyes should be evaluated along with any accompanying systemic symptoms such as fever, arthritis, or other signs of underlying systemic disease. Biopsy may be indicated in many ulcerative lesions of the oral cavity although some are more suitable for clinical diagnosis. Neoplastic ulcerated lesions are notorious in the oral cavity for their ability to mimic benign ulcerative lesions, highlighting the essential nature of biopsy to establish a diagnosis in cases that are not clinically identifiable or do not respond as expected to treatment. Adjunctive tests may be required for final diagnosis of some ulcerated lesions especially autoimmune lesions. Laboratory tests or evaluation to rule out systemic disease may be also required for recurrent or severe ulcerations especially when accompanied by other symptoms. This discussion will describe the clinical and histopathologic characteristics of a variety of ulcerated lesions found in the oral cavity.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

Management of recurrent oral herpes simplex infections

The literature has been reviewed for evidence of the efficacy of antiviral agents in both the prophylaxis and treatment of recurrent oral herpes simplex virus (HSV) infections and discussed by a panel of experts. Emphasis was given to randomized controlled trials. Management of herpes-associated erythema multiforme and Bell palsy were also considered. The evidence suggests that 5% acyclovir (ACV) in the cream base may reduce the duration of lesions if applied early. Recurrent herpes labialis (RHL) and recurrent intraoral HSV infections can be effectively treated with systemic ACV 400 mg 3 times a day or systemic valacyclovir 500 to 1000 mg twice a day for 3 to 5 days (longer in the immunocompromised). RHL in the immunocompetent can be effectively prevented with (1) sunscreen alone (SPF 15 or above), (2) systemic ACV 400 mg 2 to 3 times a day, or (3) systemic valacyclovir 500 to 2000 mg twice a day. Valacyclovir 500 mg twice a day is also effective in suppressing erythema multiforme triggered by HSV. Further studies are needed to compare treatment efficacy between topical penciclovir, docosanol, and ACV cream for RHL.

Oral manifestations of sexually transmitted diseases

Sexually transmitted diseases frequently affect the mucous membranes producing characteristic and potentially diagnostic lesions on the oral mucosa. This article reviews the classic route of transmission and the corresponding clinical presentation of several of the sexually transmitted viruses, including herpes virus types I and II, Epstein Barr virus, cytomegalovirus, human papilloma virus, molluscum contagiosum, as well as the human immunodeficiency virus. Bacterial infections such as syphilis, gonorrhea, as well as the fungus candida are reviewed under the umbrella of STDs with potential oral involvement encountered in the sexually active patient.

Acute oral ulcers

In general, a detailed history and examination of the patient provides sufficient information for diagnosis. The pattern, frequency, and natural history of ulcer episodes are helpful. The presence or absence of associated features and the site of oral involvement guides most physicians accurately in the diagnosis. Additional investigations, including blood tests, and occasionally the use of oral cultures or biopsy, are needed to make a definitive diagnosis. A multispecialty approach is often necessary to evaluate patients with other systemic features. Most acute oral ulcers heal spontaneously without specific therapy being necessary, but an understanding of the cause of the ulcer is reassuring to the patient and guides the clinician in management to prevent recurrent episodes of oral ulceration, or chronicity of ulcers.

Aphthous ulcers: a difficult clinical entity

Recurrent aphthous ulcers (RAU) are the most common oral ulcerative disease, affecting 10% to 20% of the population. There are 3 clinical subtypes-minor, major, and herpetiform. Minor aphthous ulcers are the most common subtype, representing 80% to 90% of all recurrent aphthous ulcers. Clinically, RAU present as extremely painful, shallow ulcerations with an erythematous halo on unattached oral mucosa. The primary differential diagnosis is oral herpes simplex. The etiology of RAU is unknown. Topical corticosteroids are the mainstay of therapy.

The clinical characteristics of intraoral herpes simplex virus infection in 52 immunocompetent patients

OBJECTIVE

Intraoral herpes simplex virus infection is commonly mistaken for recurrent aphthous stomatitis. The purpose of this study was to describe the clinical features of intraoral herpes simplex virus infection.

STUDY DESIGN

Fifty-two immunocompetent patients with culture-positive intraoral herpes simplex virus infection were studied.

RESULTS

The median age of the patients was 42 years. One third of the patients exhibited single ulcers; the remaining patients displayed multiple lesions. In 47 of 52 cases, the ulcers occurred on keratinized surfaces of the oral cavity; however, 5 patients had persistent ulcerations on nonkeratinized mucosa, a typical feature of herpetic ulcers in immunosuppressed patients. Of 27 patients with histories of recurrences, 22 were previously incorrectly diagnosed with recurrent aphthous stomatitis.

CONCLUSIONS

Herpes simplex virus infection of the oral cavity can usually be differentiated from other causes of recurrent oral ulcerations on the basis of its clinical appearance and distribution. The recognition of atypical features may prevent unnecessary and costly treatments for unrelated though clinically similar-appearing disorders.

Oral recrudescent herpes simplex virus infection

OBJECTIVE

The objective of this study is to determine the frequency of involvement of different intraoral sites by oral recrudescent herpes simplex virus in immunocompromised patients and whether keratinized intraoral sites are always affected by this virus.

STUDY DESIGN

The records of 30 hospitalized patients who had oral ulcers culture positive for herpes simplex virus were reviewed for the location of oral ulcers, febrile episodes, and medical diagnoses.

RESULTS

The data revealed that oral recrudescent herpes simplex virus may involve any intraoral site in immunocompromised patients with nonkeratinized sites representing approximately half of all sites; this is more frequent than has been previously reported. Twenty-six (86.7%) of 30 patients had no evidence of herpes labialis, and 13 (43.3%) of 30 patients were afebrile.

CONCLUSION

It is recommended that all oral ulcers, in immunocompromised patients should be cultured for herpes simplex virus regardless of their location. Early diagnosis reduces patient morbidity because effective treatment in the form of acyclovir is readily available.

The role of herpes simplex virus in the development of oral mucositis in bone marrow transplant recipients

Herpes simplex virus (HSV) has been implicated as a major etiologic factor in the development of ulcerative mucositis in bone marrow transplant (BMT) recipients. In this study, 60 patients who received BMTs were evaluated for at least 30 days post-transplant for ulcerative mucositis and the presence of culturable HSV. Fifty-nine patients received prophylactic acyclovir. Forty-six patients developed ulcerative lesions and 45 of these were culture negative for HSV. Neither the source of transplant (autologous versus allogenic) nor the HSV antibody status of the patient affected the frequency of mucositis. The conditioning regimen appeared to be the most significant factor contributing to the severity of ulcerative mucositis. While the majority of ulcers occurred on movable nonkeratinized mucosa in BMT recipients, the usual sites of reactivation of intraoral HSV are nonmovable, keratinized mucosa. We conclude that HSV is probably not a major etiologic agent of mucositis in BMT recipients and that acyclovir is an effective agent in preventing HSV reactivation.

Herpes simplex virus and intraoral ulcers in immunocompromised patients with haematologic malignancies

Possible factors predisposing to the development of intraoral ulcers in immunocompromised patients with haematologic malignancies were investigated. Among 46 patients undergoing antineoplastic treatment, 18 developed an intraoral ulcer during the prospective study. Patients with or without ulcers were comparable with respect to underlying disease, presence of teeth, the qualitative composition of the aerobic and facultatively anaerobic oral microflora, herpes simplex virus (HSV) titer positivity, a past history of herpes labialis, leukocyte and thrombocyte counts, and duration of fever. Viral cultures from saliva revealed an association between the presence of HSV in saliva and the presence of intraoral ulcers. HSV was not isolated from the saliva of any patient without ulcers. Viral cultures from the ulcers revealed growth of HSV in 11 (61%) of the 18 patients with ulcers. HSV-positive ulcers were located more often on the alveolar process than elsewhere in the oral cavity. Ulcers on the lateral borders of the tongue and on the buccal mucosa were found only in dentate patients. Development of intraoral ulcers was not associated with an increase of the HSV titer in serum in any patient. It is concluded that some intraoral ulcers, especially when located on the alveolar process, are associated with and probably caused by HSV, while mechanical trauma during mastication seems likely to be involved in the pathogenesis of ulcers elsewhere in the oral cavity.

Mucosal pain disorders of the head and neck

Painful disease processes that affect the mucous membranes of the upper aerodigestive tract include viral and bacterial infections, hypersensitivity reactions, and immunopathologic disorders. The diagnosis and treatment of the most common diseases that cause pain are described.

Ocular shedding of herpes simplex virus

The presence, frequency, and relationship of ocular and oral shedding of herpes simplex virus to previous herpes keratitis was investigated. This was to determine if a history of herpes keratitis predisposes to shedding of the herpes simplex virus into the tear film and/or mouth. Swabs were collected from the eyes and mouth of two groups of patients thrice weekly over a two- to four-month period. Group A comprised nine patients with a history of herpes labialis, group B 15 patients with a history of herpes keratitis. Herpes simplex virus type 1 was isolated from 1.33% of mouth specimens but was not identified in any of the ocular specimens. There was no significant difference between groups A and B in terms of ocular or oral shedding. Oral shedding appears to be independent of a previous herpes keratitis. The tear film is an unlikely source of virus in persons either with no history of herpes keratitis or between attacks in those patients with a history of previous herpes keratitis.

Diagnosis of oral herpes simplex virus infections: practical aspects of viral culture

Viral culture is a valuable aid in the diagnosis of herpes simplex virus infections of the oral cavity, but it is underutilized by members of the dental profession. This article outlines indications for culture, practical aspects of collection and transportation of specimens, reasons for false-negative and false-positive test results, and cost.

Pathogenesis of herpes simplex labialis: excretion of virus in the oral cavity

Excretion of herpes simplex virus (HSV) in the oral cavity was studied in eight human subjects with a history of herpes labialis. Serial intraoral specimens were obtained by gargling broth and examined for virus by centrifugal inoculation of primary human amnion cells. Forty-seven of 637 specimens (7.4%) contained HSV. The majority of isolates (62%) were found in clusters, and the rate of excretion was significantly increased during the common cold (21%) and after oral trauma (17%) (P = 0.001 and 0.04, respectively). Oral HSV excretion often occurred in parallel with episodes of herpes labialis but could not be attributed to viral contamination from a labial lesion. Each patient excreted only one strain of HSV type 1 as determined by restriction endonuclease analysis with KpnI and BamHI. Unexpectedly, prodromal symptoms of herpes labialis were commonly not followed by development of a lesion (false prodrome). False prodromes were associated with a high rate of oral HSV excretion (60%). Intraoral ulcers on the gingivae and hard palate were frequently associated with oral HSV excretion (31%) and are the most likely source of HSV in the oral cavity.

Inheritance patterns in recurrent aphthous ulcers: twin and pedigree data

Nineteen sets of twins and 318 individuals from six families were examined and interviewed in order to ascertain whether a genetic component could be established for recurrent aphthous ulcers (RAU). While no specific mode of inheritance could be established, the data strongly support the hypothesis of a genetic factor involved in susceptibility to the disease.

Recurrent oral and oculogenital ulcerations (Behçet's syndrome)

The literature on Behçet's syndrome is reviewed and four cases are presented. Two of the patients were men and two were women. The age at presentation varied from 21 to 55 years. All patients had the first manifestations of the disease before the age of 25 and two before the age of 10. None presented with the complete triad of symptoms. All four had oral ulceration and either ocular lesions (two cases) or lesions on the genitals (two cases). According to the present theories, the diagnosis of Behçet's syndrome is established by the presence of any two of the triad of symptoms. We suggest that in order to be classified as having Behçet's syndrome, a patient should have oral lesions and either genital and/or ocular ulcerations.

[Inflammatory and systemic reactions of the mouth mucosa]

The field of oral medicine is fundamental to the practice of general medicine as well as dentistry, oral surgery, and other special fields of medicine concerned with diseases of organs beneath the oral cavity. Disorders of the oral mucosa may reflect many dermal and internal diseases, and may focus the physician's diagnostic attention to systemic pathological conditions which otherwise could be misdiagnosed. As to their morphological appearance, however, the oral mucosa shows other forms of reactivity than the skin. When the dermal and oral manifestations of many skin diseases are compared the influence of distinct local factors on the intraoral clinical picture becomes evident. This comparative view, as well as the dermatologist's practical experience that many dermatoses either spread to, or even are restricted to the oral mucosa, may explain why most dermatologists are very interested in oral diagnosis. In this report, the interdisciplinary view and some aspects of clinical stomatology are stressed which are of actual interest in oral diagnosis and therapy. The following topics are dealt with: Diseases with aphthous lesions, Allergic reactions to drugs, Pemphigus and pemphigoid disorders, Oral infections by Candida albicans, Melkersson-Rosenthal syndrome, Lingual anomalies of different types, Leukoplakias.

Complications of free grafts of masticatory mucosa

A discussion has been presented and examples provided to illustrate some of the complications that may be encountered in conjunction with free grafts of masticatory mucosa. The clinical problems presented are seen infrequently, but the clinician must be aware of the possibility of their occurrence when counseling patients on the possible sequelae of such surgical procedures. A knowledge of complications that may occur in free soft tissue grafting procedures, and of the underlying mechanisms causing these problems, may aid the clinician in anticipating and avoiding similar experiences.