Chapter 1 SORE MOUTH
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?
finger breadths can be inserted between upper and lower incisors.CAUSES OF SORE MOUTH
| Trauma | Gastrointestinal |
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.
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.
