Case #25 Discussion

Summary: This is a vesicular-ulcerated-erythematous surface lesion.    ~The patient has had chronic, persistent, generalized, painful oral ulcers of three months duration. Lesions to Exclude from the Differential Diagnosis: Epidermolysis Bullosa   ~Almost all cases begin at birth or early childhood   ~Skin lesions are consistently present Viral Infection   ~Acute onset and resolution of blisters and ulcers. Candidosis   ~Causes white lesions which rub off or painful erythematous mucosa rather than strictly ulcers. Idiopathic Diseases   ~Aphthous Ulcers *Abrupt onset and healing in a predictable amount of time   ~Erythema Multiforme *Acute onset *Resolves in 2-6 weeks   ~Epithelial dysplasia, Carcinoma-in-situ, and squamous cell carcinoma *Occurs as erythroplakia and/or leukoplakia rather than strictly as painful oral ulcers.   ~Contact stomatitis *No history of contact with cinnamon, other flavoring agents, dentifrices, mouthrinses Autoimmune Diseases   ~The pattern of chronic persistent ulcers is often seen in autoimmune diseases.   ~Bullous Pemphigoid can be excluded because it has skin lesions. Lesions to Include in the Differential Diagnosis: Pemphigus, Mucous Membrane Pemphigoid, Lichen Planus   ~These three autoimmune diseases are part of the differential diagnosis. Lupus Erythematous   ~Less likely than the other autoimmune diseases because most oral lesions of lupus are accompanied by skin lesions. Medication-Induced Mucositis   ~This should be part of the differential diagnosis because gold salts can cause chronic oral ulcers   ~Note that the ulcers do not necessarily begin as soon as the patient begins taking the medication. Management: Several approaches can be used to obtain a definitive diagnosis.  Explain to the patient the nature of the diseases in the differential diagnosis and of the need for a definitive diagnosis.  Then, discuss with the patient’s physician the possibility of replacing the medication (gold salts) with a different medication to treat rheumatoid arthritis.  If the oral ulcers resolve, then the diagnosis is medication-induced mucositis.   An incisional biopsy can, and probably should, be performed to check for pemphigus, mucous membrane pemphigoid and lichen planus.  The incisional biopsy should be from the edge of the ulcer and consist mainly of non-ulcerated tissue.   In this case the patient’s ulcers resolved once the gold salts had been replaced by a different medication. Final Diagnosis: Medication-induced mucositis