Definition:
Necrotic or eroded oral mucosa, including tongue. Most such lesions are idiopathic (apthous) or of viral etiology, although they also may be due to fungal, parasitic, or bacteriologic pathogens. Herpetic ulcerations tend to appear on keratinized tissues such as the hard palate or gingiva. Aphthous ulcerations tend to manifest on non-keratinized tissues such as the floor of the mouth, soft palate and lingual (bottom) surface of the tongue.
S: Patient complains of painful ulcerative areas in mouth. May have difficulty eating, drinking, swallowing, or opening mouth. May also complain of sore throat.
Hx: Inquire about other ulcerative gastrointestinal diseases, including HSV, CMV or histoplasmosis; r/o trauma, burn. Note current drugs, particularly zalcitabine (ddC) and dapsone; inquire about ETOH and smoking history.
O: Red or white-bordered erosions or ulcerations varying in size from 1 mm to 2 cm on buccal mucosa, oropharynx, tongue, lips, gingiva, hard or soft palate.
A: R/O recurrence of previous gastrointestinal/oral lesions, such as HSV, CMV, idiopathic lesions, histoplasmosis, or drug-induced ulceration. HSV lesions may appear as clusters of vesicles that may coalesce into ulcerations with scalloped borders
Lab: May perform HSV cultures on oral ulcerations which appear on keratinized tissues or the dorsal and lateral surfaces of the tongue, scraping near margin of lesion; or open fresh vesicle if available. Negative HSV cultures increase when collections are taken from older, resolving herpetic areas; usually herpetic lesions >72 hours old will not yield a positive culture.
P: If HSV culture is positive, or if HSV is strongly suspected due to appearance, hx, or recurrence, treat with acyclovir while awaiting results of culture. Do not use topical steroids without concomitant acyclovir if lesion is of possible herpetic etiology.
If patient is on ddC or dapsone, try to substitute other agents and check for improvement in lesions.
Recalcitrant aphthous ulcerations should be treated with topical corticosteroids. For multiple small lesions, use Decadron (dexamethasone) elixir, 5 cc qid--rinse and hold as long as possible, 1-2 minutes, then spit. Continue treatment for one week, observing until lesions resolve. If no resolution or improvement in one week, oral corticosteroids may be needed: Prednisone 40 mg po qd for one week. If this is ineffective, request biopsy to rule out CMV, HSV, or neoplastic disease.
Assess nutritional status and consider adding Avera, Ensure, Boost, Sustacal, or other liquid food supplement if food intake has decreased or weight loss occurs. Refer to dietician.
Pain control is important in this case to maintain food intake and prevent weight loss:
1) Topicals: For small accessible ulcerations, apply Orabase Soothe-N-Seal (2-octyl cyanoacrylate) directly to the lesion q 4-6 hours. (This is an over the counter product.)
2) For larger ulcerations or those which present in the posterior oropharynx, prescribe Gelclair Dose packs (disp 4) Rinse for 1-2 minutes then expectorate TID. As with all oral topicals, inform patients not to eat or drink for at least 30 minutes after the application.
3) Hurricaine spray (xylocaine viscous) prn; swish and expectorate.
4) Systemic: see pain
management protocol.
Refer to Oral Health or HIV-expert dentist as needed.
Refer to registered dietician if client is having pain, problems eating, or weight loss.
Note: Thalidomide 200 mg qd x 2 weeks is available for oral apthous ulcers. It should not be used in women of child-bearing potential due to its teratogenicity. If no other alternative, it must be used very carefully with thorough patient education, pregnancy testing, and 2 concomitant methods of birth control.