Adult Oral Health Clinical Case #2

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Question 1 of 3

1. Question
Tanya is a 20 year old female who presents to your office with a painful mouth sore that has been present for three days. The sore developed spontaneously and has not changed since its appearance. Six months ago, she noticed similar sores that resolved spontaneously after two weeks. She denies fever or systemic symptoms. Your oral exam reveals the following:

Joanna Douglass, BDS, DDS

What is the most likely cause of Tanya’s oral lesion?
- Primary oral herpes Primary oral herpes is normally seen in preschool children. The ulcerations caused by primary oral herpes typically occur in multiple locations throughout the mouth and patients normally have concurrent fever and malaise. However, diagnosis can be difficult with patients presenting with little or no fever and malaise and only single lesions early in the disease course. Although most common in younger children, teenagers can present with primary oral herpes. In this case the fact that Tanya had similar symptoms once before argues against the diagnosis of primary herpes infection.
- Gingival trauma Traumatic ulcerations typically occur in areas of the mouth that are easily traumatized by teeth or rough dental restorations. They are often deeper than aphthous or viral ulcers with a larger amount of adherent yellow or white discharge than an aphthous ulcer. Traumatic ulcers commonly occur in children or developmentally disabled individuals after receiving local anesthesia. The source of trauma should match the traumatized area. An example is shown in the photo right where a child bit their lip after dental anesthesia:
- Coxsackie virus Coxsackie virus infections typically occur in young children and are preceded by fever. Vesicles then erupt on the tongue, oral mucosa, palms, and soles. While the vesicles can ulcerate, they typically do so later in their course.
- Aphthous ulcer
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Question 2 of 3

2. Question
Which of the following is true regarding Recurrent Aphthous Ulcers (RAU)?
- These lesions commonly present as a single painful ulcer that resolves after two months. RAU may present in three clinical forms-minor, major and herpetiform variants. The prevalence of RAUs is between 2% to 50%, however most studies suggest the prevalence ranges between 5% to 25%. RAU may occur throughout the life span with the peak age between 10-19 years. The minor variant is most common, affecting up to 80% of RAU patients and is the most common form in children. Minor lesions (<10mm in diameter) are painful shallow ulcers with a grey-white pseudomembrane surrounded by a thin erythematous halo that occur spontaneously as single or multiple ulcers They heal without scarring in 1-14 days. Major lesions affect approximately 10% of RAU patients, are similar to minor RAU, but are larger that 10mm. Major lesions may last up to 6 weeks or longer and usually heal with scarring. The least common form is the herpetiform variant. These may be confused with primary oral herpes, however, herpitform RAU are not preceded by vesicles. This variant is characterized by multiple recurrent small painful ulcers 2-3 mm in diameter as illustrated in the photo above. They typically heal without scarring in 7-10 days.
- RAUs have been associated with vitamin deficiencies.
- Most lesions require immediate treatment with topical steroids. Most patients with RAU have mild disease and do not require treatment. However, those with severe pain, multiple lesions, or difficulty eating may be treated with topical agents such as glucocorticoids gels, or anesthetics such as viscous lidocaine hydrochloride. Systemic steroids may be considered in severe and constantly recurring ulcerations. Prior to treatment, possible underlying causes should be ruled out.
- These lesions typically occur on keratinized mucosal surfaces such as the gingival and hard palates. RAU typically occurs on non-keratinized mucosa in labial and buccal locations, and the floor of the mouth. They rarely present on the keratinized gingiva, palate or dorsum of the tongue.
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Question 3 of 3

3. Question
Two months later Tanya returns with similar complaints. She has developed recurrent painful month sores that resemble her previous lesions. The lesions have been present for almost 2 weeks. In the past, her pain was minimal, but she now reports that it has become painful to eat, drink and speak. She has tried over the counter mouth rinses without much improvement.

Which of the following is the most appropriate next step in management?
- Refer Tanya to an oral surgeon for biopsy of her lesion. Referring Tanya for biopsy is unnecessary. RAU are diagnosed by history and their typical appearance on physical examination.
- Prescribe Thalidomide. In severe and persistent cases of RAU, thalidomide has been prescribed. However, it is not a first line agent and is not appropriate for Tanya’s relatively mild disease. Thalidomide should be reserved for severe, resistant cases and be prescribed in conjunction with specialist consultation as it has many potentially severe side effects.
- Prescribe topical steroids.
- Prescribe an antiviral medication. Although no clear etiology for RAU has yet been identified, a viral etiology has not been established. Therefore, antiviral treatments are not recommended.
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Adult Oral Health

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