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ACUTE ORAL ULCERS
L E T T E R S
ACUTE ORAL ULCERS
After reading Drs. Nathaniel Treister and Mark Lerman’s April JADA article, “Acute Oral Ulcerations” (JADA 2007; 138[4]:499-501), I feel that the diagnosis is not satisfactory and does not appear in the differential diagnosis. The patient gave us the active diagnosis in the article’s first paragraph. She stated that she had a burning sensation while eating salad dressing, and that this was the worst pain that she had ever experienced. The description and photos match a chemical burn and/or contact allergic dermatosis diagnosis due to the food that she was eating. Burns are painful, and the lesions were strictly limited to contact surfaces while eating. I would consider several possible offending agents, such as habanero or other hot peppers, hot mustards and curry. Other foods also are possible. The fact that she was divorced and recently had been dating someone is significant, since she probably was eating different foods at different restaurants. I don’t believe the fact that her new companion had a history of herpes labialis is the significant feature in her social history. The diagnosis of herpetic gingivostomatitis is a red herring (a clue that leads us away from the truth). The majority of the adult population would be positive for herpes simplex virus-1 (HSV-1). There is an excellent article published by Stoopler and colleagues1 that details procedures to diagnose herpes simplex viruses definitively. There was no histologic evidence to evaluate when only 1062
JADA, Vol. 138
a viral culture is obtained with a swab across the entire mouth. Also, there were no reported symptoms of fever and cervical lymphadenopathy that would be associated with primary herpetic stomatitis, and the age points away from this diagnosis. The treatment that she received at the emergency room was appropriate. The bismuth salicyclate coats the mucous membranes. The lidocaine would alleviate the pain. The diphenhydramine hydrochloride would treat the allergic dermatosis. Use of the antiviral drug, acyclovir, seemed inappropriate to me. The patient should be advised to discover what was in her salad and dressing so that she does not have a recurrence that could prove to be more severe. She may indeed be positive for HSV-1, but a patient can present with multiple diagnoses. Let’s say that a patient arrived at an emergency room with a broken leg, and a routine blood profile discovered that the patient was hyperglycemic. The diagnosis may be diabetes, but the active diagnosis still is a broken leg. More than one diagnosis is possible. It can be difficult in this case, in which both are in the mouth. All practitioners should consider that more than one diagnosis is possible, and that one positive diagnosis does not exclude others. Joan E. Albrecht, DDS North Platte, Neb. 1. Stoopler ET, Pinto A, DeRossi SS, Sollecito TP. Herpes simplex and varicellazoster infections: clinical and laboratory diagnosis. Gen Dent 2003;51(3):281-6.
Authors’ response: We would like to thank Dr. Albrecht for her interest in our
recent article. We agree that considering alternate diagnoses is always of the utmost importance. In this case, however, we believe that a diagnosis of chemical burns or contact mucositis secondary to food is extremely unlikely. A presentation of diffuse ulcers throughout the oral mucosa may be consistent with exposure to a caustic substance,1 but we have found no reported cases in the literature associated with salad dressing or spicy foods. It is true that there are reports of contact mucositis secondary to eating, in which patients may complain of a burning sensation. Objective examination of these patients typically reveals the oral mucosa varies in appearance from mild to severe erythema with or without edema.2 This is inconsistent with the clinical picture seen in our case. While it is true that primary herpetic gingivostomatitis is seen most often in children, there have been numerous cases reported in older individuals as well. The patient’s positive viral culture also supports this diagnosis, as swabbing lesional tissue for viral culture is an appropriate technique for identifying herpes.3 That our patient has had no recurrences one year later is also consistent with this diagnosis, as the disease presents as a solitary episode. Contact mucositis, on the other hand, is a condition that commonly recurs. We appreciate Dr. Albrecht’s interest in our patient. However, we believe that she received the correct diagnosis and are comfortable with the treatment provided. Nathaniel S. Treister,
http://jada.ada.org August 2007 Copyright ©2007 American Dental Association. All rights reserved.
ACUTE ORAL ULCERS
After reading Drs. Nathaniel Treister and Mark Lerman’s April JADA article, “Acute Oral Ulcerations” (JADA 2007; 138[4]:499-501), I feel that the diagnosis is not satisfactory and does not appear in the differential diagnosis. The patient gave us the active diagnosis in the article’s first paragraph. She stated that she had a burning sensation while eating salad dressing, and that this was the worst pain that she had ever experienced. The description and photos match a chemical burn and/or contact allergic dermatosis diagnosis due to the food that she was eating. Burns are painful, and the lesions were strictly limited to contact surfaces while eating. I would consider several possible offending agents, such as habanero or other hot peppers, hot mustards and curry. Other foods also are possible. The fact that she was divorced and recently had been dating someone is significant, since she probably was eating different foods at different restaurants. I don’t believe the fact that her new companion had a history of herpes labialis is the significant feature in her social history. The diagnosis of herpetic gingivostomatitis is a red herring (a clue that leads us away from the truth). The majority of the adult population would be positive for herpes simplex virus-1 (HSV-1). There is an excellent article published by Stoopler and colleagues1 that details procedures to diagnose herpes simplex viruses definitively. There was no histologic evidence to evaluate when only 1062
JADA, Vol. 138
a viral culture is obtained with a swab across the entire mouth. Also, there were no reported symptoms of fever and cervical lymphadenopathy that would be associated with primary herpetic stomatitis, and the age points away from this diagnosis. The treatment that she received at the emergency room was appropriate. The bismuth salicyclate coats the mucous membranes. The lidocaine would alleviate the pain. The diphenhydramine hydrochloride would treat the allergic dermatosis. Use of the antiviral drug, acyclovir, seemed inappropriate to me. The patient should be advised to discover what was in her salad and dressing so that she does not have a recurrence that could prove to be more severe. She may indeed be positive for HSV-1, but a patient can present with multiple diagnoses. Let’s say that a patient arrived at an emergency room with a broken leg, and a routine blood profile discovered that the patient was hyperglycemic. The diagnosis may be diabetes, but the active diagnosis still is a broken leg. More than one diagnosis is possible. It can be difficult in this case, in which both are in the mouth. All practitioners should consider that more than one diagnosis is possible, and that one positive diagnosis does not exclude others. Joan E. Albrecht, DDS North Platte, Neb. 1. Stoopler ET, Pinto A, DeRossi SS, Sollecito TP. Herpes simplex and varicellazoster infections: clinical and laboratory diagnosis. Gen Dent 2003;51(3):281-6.
Authors’ response: We would like to thank Dr. Albrecht for her interest in our
recent article. We agree that considering alternate diagnoses is always of the utmost importance. In this case, however, we believe that a diagnosis of chemical burns or contact mucositis secondary to food is extremely unlikely. A presentation of diffuse ulcers throughout the oral mucosa may be consistent with exposure to a caustic substance,1 but we have found no reported cases in the literature associated with salad dressing or spicy foods. It is true that there are reports of contact mucositis secondary to eating, in which patients may complain of a burning sensation. Objective examination of these patients typically reveals the oral mucosa varies in appearance from mild to severe erythema with or without edema.2 This is inconsistent with the clinical picture seen in our case. While it is true that primary herpetic gingivostomatitis is seen most often in children, there have been numerous cases reported in older individuals as well. The patient’s positive viral culture also supports this diagnosis, as swabbing lesional tissue for viral culture is an appropriate technique for identifying herpes.3 That our patient has had no recurrences one year later is also consistent with this diagnosis, as the disease presents as a solitary episode. Contact mucositis, on the other hand, is a condition that commonly recurs. We appreciate Dr. Albrecht’s interest in our patient. However, we believe that she received the correct diagnosis and are comfortable with the treatment provided. Nathaniel S. Treister,
http://jada.ada.org August 2007 Copyright ©2007 American Dental Association. All rights reserved.