mouth ulcers and EN

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BACKGROUND

Mouth ulcers are open lesions or sores in the mouth that can be caused by many different disorders or conditions, such as viral or fungal infections, immune deficiency, or cancer. Types of mouth ulcers include acrodermatitis enteropathica, canker sores, cold sores, oral leukoplakia, oral candidiasis (oral thrush), and oral mucositis.

Acrodermatitis enteropathica is a medical condition in which the body is unable to absorb zinc.

Canker sores are common but mostly harmless, and they appear inside the

mouth as white or gray ulcers, which are eroded areas of the oral cavity that are marked by tissue disintegration, with a red border. A small percentage of patients may develop severe canker sores (complex aphthosis), which are persistent and painful sores. In infants, painful sores may interfere with eating and may require a visit to the pediatrician. In patients with a weakened immune system (for example, patients who are HIV positive or receiving chemotherapy), the fungus may

spread throughout the body, causing infection in the esophagus (esophagitis), brain (meningitis), heart (endocarditis), joints (arthritis), or eyes (endophthalmitis).

Cold sores, or herpes labialis, is a condition that involves sores on the lips and inflammation of the gums and mouth. It is caused by the herpes simplex virus type 1 (HSV-1).

Oral leukoplakia is a condition in which thickened, white patches form on the gums, on the inside of the cheeks, and sometimes on the tongue. The cause of leukoplakia is unknown, but it is considered to result from

chronic irritation. A subtype of leukoplakia is oral hairy leukoplakia (OHL). Hairy leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with the human immunodeficiency virus (HIV) or have acquired immunodeficiency syndrome (AIDS) or AIDS-related complex.

Oral thrush is a fungal or yeast infection in the mouth caused by an overgrowth of the fungus Candida albicans.

Oral mucositis is an inflammation of mucous membranes of the mouth, and

it has been reported in many patients receiving radiation therapy.

Symptoms of mouth ulcers include pain and redness at the site of the lesion. Diagnosis is usually performed by examination of the appearance of the lesion or further tests, such as a blood test or biopsy. Treatment involves oral hygiene, topical preparations, and avoidance of irritating substances on or near the lesion.

TYPES OF THE DISEASE

Acrodermatitis enteropathica: Acrodermatitis enteropathica is an inherited condition that occurs when the body is unable to absorb zinc. This trace element is necessary for the functioning of more than 300 different enzymes, which are proteins that either increase or decrease the rates of chemical reactions. Zinc plays a vital role in many other biological processes as well. Symptoms of this disease, including skin lesions or sores, hair loss, and diarrhea, often develop soon after birth in infants who are bottle fed or when an infant is weaned from breastfeeding. Lesions are any abnormal area on or in a tissue, such as an injury, wound, boil, sore, rash, moles, warts, or cysts.

Canker sores: Canker sores, also known as aphthous stomatitis or an inflammation of the mouth, are common but often harmless. They appear inside the mouth as ulcers that are white or gray with a red border. Ulcers are eroded areas of the oral cavity that are marked by tissue disintegration. The reason canker sores appear is unknown but some experts believe that problems with the immune system (the body system that fights disease, bacteria, and viruses) may be involved.

Canker sores are usually seen in children and adolescents 10-19 years old. For about one-third of the children affected, lesions continue to reappear for years after the initial outbreak. These ulcers are not contagious and cannot be spread from one child to another. Canker sores also occur in women more often than men, often during menstrual periods.

The sores are not considered to be precancerous.

Cold sores (herpes simplex virus): Herpes simplex type 1 (HSV-1) is also known as a cold sore or a fever blister. Herpes simplex type 1 infections are generally marked by painful, watery blisters on the skin or mucous membranes, such as the mouth or lips. Lesions heal with a crust-forming scab, which is the hallmark of herpes. The virus is particularly contagious during an outbreak, although individuals may be rid of the virus between outbreaks.

HSV-1 is a common virus. It is thought that 90% of adults have been exposed to the virus during their lifetimes, and most Americans have contracted the virus by the age of 20. Most people contract oral herpes when they are children by receiving a kiss from a friend or relative who

is carrying the virus. Some patients may not have an initial outbreak until years later. After the first episode, the virus lies dormant in the nerves or the skin around the original area until something sets off

the virus into another eruption. Colds, the flu, and stress may cause an outbreak of cold sores. It is not well understood why individuals have outbreaks at one time of life and not another.

Leukoplakia: Leukoplakia is the most common cause of all chronic mouth lesions. Although anyone can develop leukoplakia, it is most common in older men.

Oral leukoplakia is a condition in which thickened, white patches known

as leukoplakic patches form on the gums, the inside of the cheeks, and sometimes the tongue. The cause of leukoplakia is considered to result from chronic irritation. Tobacco, either smoked or chewed, is the most common cause, but irritation may also come from other sources, such as long-term alcohol use. Leukoplakia may also be caused by irritations such as an ill-fitting denture or the habit of chewing on the inside of the cheek.

In general, leukoplakia is not painful, but the patches may be sensitive when the individual touches them or eats spicy foods. Although

the disorder usually is not dangerous, a small percentage of leukoplakic patches show early signs of cancer. Many cancers of the mouth occur next to areas of leukoplakia. For that reason, it is best to

see a dentist if there are unusual changes in the mouth lasting longer than a week.

People with compromised immune systems sometimes develop an unusual form of the disorder called hairy leukoplakia. Hairy leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with the human immunodeficiency virus (HIV) or have acquired immunodeficiency syndrome (AIDS) or AIDS-related complex. Hairy

leukoplakia consists of corrugated, fuzzy (hence the name "hairy"), white patches on the lateral borders of the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida albicans.

Mucositis: Mucositis, or stomatitis, is inflammation of the mucous membranes lining the digestive tract from the mouth to the anus. Mucositis is a common side effect of chemotherapy and of radiotherapy that involves any part of the digestive tract, such as the mouth or the stomach. Chemotherapy is the treatment of cancer using specific chemical

agents or drugs that are selectively destructive to malignant cells and

tissues. Radiotherapy uses radiation or radioactive substances to treat

disease.

Mucositis affects the rapidly dividing mucosal cells lining the mouth, throat, stomach, and intestines. These cells normally have a short life span. Chemotherapy or radiation therapy can destroy these cells quickly,

and they may not immediately regenerate, leading to ulcers or sores. Mild mucositis is painful and may require pain medication for a week or two until the tissues recover. In severe cases of mucositis, a growth factor (a substance that affects the growth of a cell or an organism, such as palifermin or keratinocyte growth factor) and parenteral alimentation (providing nutrition through the veins) may be needed.

Damage to the mucosal cells also makes it difficult for the mouth to heal and fight off bacteria, leading to infection. Healthcare professionals recommend seeing a dentist regularly during chemotherapy or radiation treatment. Good mouth care, including the use of saltwater mouth rinses, and adequate hydration may prevent infection, bleeding, and difficulty eating and swallowing.

Oral candidiasis (also called moniliasis or oral thrush): Oral thrush is a fungal or yeast infection (candidiasis) in the mouth caused by an overgrowth of the fungus Candida albicans. Oral thrush appears in the mouth as red or white lesions, which are flat or slightly raised. The patches have varying sizes and shapes. When severe, this fungus can spread down the esophagus, making chewing and swallowing very painful. The esophagus, which is also known as the food pipe, is the body canal (tube) that carries food from the mouth to the stomach.

The patches are common among denture wearers and occur most often in those who are very young, the elderly, or those who have a suppressed (or weakened) immune system, such as cancer and HIV/AIDS patients. Individuals who have xerostomia (dry mouth syndrome) and those taking antibiotics may also get oral yeast infections.

The Candida albicans fungus is found almost everywhere in the environment, which is why most people have small amounts of Candida albicans in their mouths at any given time. However, individuals with healthy immune systems are usually able to prevent the fungus from multiplying and causing an infection. In rare cases, when candidiasis affects healthy individuals, symptoms are usually minor. In contrast, immunocompromised patients, such as patients infected with the human immunodeficiency virus (HIV) or patients receiving immunosuppressants (for example, Imuran©, cyclosporine, or methotrexate), often suffer from

severe symptoms, including painful lesions in the mouth, that may make it difficult to eat.

Use of oral antibiotics, especially broad-spectrum antibiotics that have activity against a wide range of disease-causing bacteria, has been

associated with an increased occurrence of yeast infection. Antibiotic use may eliminate normal, healthy bacteria, which may allow for the overgrowth of the fungus Candida albicans. Antibiotics have also been detected in animal products such as meat, poultry, and cow's milk. In human research, significantly higher Candida albicans counts were found in the stool of patients with antibiotic-associated diarrhea (AAD). Candidiasis infections are generally treated with antifungals for 10-14 days.

RISK FACTORS

Canker sores: The American Dental Association (ADA) has identified fatigue, stress, and allergies as potentially increasing the chances of getting a canker sore. Similarly, patients with lowered immune systems or intestinal problems, such as ulcerative colitis and Crohn's disease, may be more susceptible to developing canker sores.

Celiac disease: Celiac disease, also called celiac sprue, is a digestive disorder that occurs when an individual's immune system overreacts to the protein gluten or other proteins within gluten (such as gliadin) found in grains, including wheat, rye, barley, and, to some degree, oats. When a patient with the disease eats food that contains gluten, the immune system's response damages the intestinal lining. This

causes symptoms of abdominal pain and bloating. Additionally, complications, including poor absorption, may occur if the patient continues to eat gluten-containing foods. When the intestinal lining is damaged, patients have difficulty absorbing nutrients.

It has not been determined what triggers this reaction in celiac patients. However, celiac disease is associated with autoimmune disorders, such as lupus. Autoimmune disorders occur when the patient's immune system mistakenly identifies body cells as harmful invaders, such

as bacteria. As a result, the immune cells in celiac patients attack the patient's own intestinal cells.

Researchers at the National Digestive Diseases Information Clearinghouse (NDDIC) estimate that one out of 133 people in the United States have celiac disease. The prevalence is even higher (one out of 22

people) among patients who have immediate family members (a parent or sibling) who have the disease. This suggests that the disease may be inherited (passed down through families) in some cases. Individuals can develop the disease at any age, but it is most commonly diagnosed in patients who are 8-12 months old or 30-40 years old.

Although there is currently no cure for celiac disease, the condition can be managed with a gluten-free diet. In general, patients who strictly follow a gluten-free diet can expect to live normal, healthy lives. Symptoms will subside in several weeks, and patients will be able

to absorb food normally once they avoid eating gluten. A dietician or certified nutritionist may help a patient with celiac disease develop a healthy diet. Patients with celiac disease may also find gluten-free cookbooks to be a helpful resource. Many products, including rice flour and potato flour, can be used as substitutes for gluten.

Cold sores (herpes simplex virus): Everyone is at risk for HSV-1 (herpes labialis or oral herpes). It is easily transmitted and is the most common form of the herpes simplex virus. According to the American Social Health Association, about 50-80% of adults in the United States have oral herpes.

HSV-1 can be spread by close contact with someone who has a cold sore or by using items contaminated with the virus. Kissing someone on the mouth will spread the virus, and sharing personal items such as razors, towels, or eating utensils with a person who has oral herpes will increase the risk of getting HSV-1. The virus can also be spread to the genital area of another individual through oral sex. Healthcare practitioners suggest that individuals with oral herpes not perform oral

sex on their partners. They should also avoid kissing during outbreaks.

Infants and young children (up to three years old) have an increased risk of being exposed to HSV-1 due to immune systems that are still not fully developed.

Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease

(GERD), also called acid reflux disease, occurs when liquid from the stomach regurgitates (backs up) into the esophagus. This liquid may contain stomach acids and bile. In some cases, the regurgitated stomach liquid can cause inflammation (esophagitis), irritation, and damage to the esophagus.

It remains unknown exactly what causes GERD. Several factors, including

hiatal hernias (when the stomach pushes up through a hole in the diaphragm muscle), abnormally weak contractions of the lower esophageal sphincter, and abnormal emptying of the stomach after a meal, have been associated with GERD.

Common symptoms of GERD include a burning sensation in the chest that may spread to the throat (heartburn), chest pain (especially when lying down), dysphagia (difficulty swallowing), regurgitating food or sour liquid, coughing, hoarseness, sore throat, and wheezing.

Several factors may worsen symptoms of the condition. For instance, spicy foods, fatty foods, chocolate, caffeine, tomato sauce, carbonated beverages, mint, alcoholic beverages, large meals, lying down after eating, some medications (e.g., sedatives, tranquilizers, or blood pressure drugs), and cigarette smoking may worsen symptoms of GERD.

GERD is usually a lifelong condition, because there is no cure for the disorder. Patients must take medications for the rest of their lives to manage the symptoms. In addition, patients should not smoke, because it may increase the amount of stomach acid and worsen symptoms.

Leukoplakia: Although anyone can develop leukoplakia, it is most common

in older men. The American Dental Association (ADA) suggests that tobacco use appears to be responsible for most cases of leukoplakia, although other risk factors may include ill-fitting dentures or cheek biting.

Mucositis: Oral mucositis is a frequent complication of anticancer treatment. Its incidence varies, depending on the patient and treatments

themselves. In a review article, Volpato et al. reported that patients with cancers of the blood, such as leukemia and lymphoma, tend to show a

2-3 times higher rate of oral complications than patients with solid tumors. Similarly, young patients (less than 12 years of age) may be more susceptible to chemotherapy-induced oral adverse effects. Certain chemotherapy agents are more likely to cause this side effect, such as cytarabine (Cytosar-U©), doxorubicin (Adriamycin©), and methotrexate (Rheumatrex©). Most patients receiving radiotherapy in the head and neck

develop some degree of mucositis. It has been reported that mucositis almost always occurs in patients receiving a combination of chemotherapy

and radiotherapy.

Factors that may increase the risk of developing mucositis include poor

oral or dental health, smoking, chewing tobacco products, drinking alcohol, dehydration, and diseases such as kidney disease, diabetes, or HIV/AIDS. These risk factors may also worsen the condition once it has developed.

Oral candidiasis (oral thrush): Candida albicans is normally present in

a person's mouth. According to the American Dental Association (ADA), oral thrush commonly occurs in patients who are very young, the elderly,

and those with diseases such as diabetes or leukemia or those with weakened immune systems, such as HIV patients. People with xerostomia (dry mouth syndrome) are also more likely to suffer from candidiasis. Use of oral antibiotics, especially broad-spectrum antibiotics, such as levofloxacin or tetracycline, with activity against a wide range of disease-causing bacteria may decrease normal bacteria in the mouth and cause Candida to flourish, resulting in candidal infections.

CAUSES

Acrodermatitis enteropathica: The exact cause of acrodermatitis enteropathica (an inborn error of zinc metabolism) remains unclear and continues to be debated. However, researchers believe that genetics may play a role and this condition and that it may be an inherited autosomal

recessive disorder. An autosomal chromosome is a non-sex chromosome. Differences in the prevalence of the condition among races have yet to be reported.

Canker sores: The reason canker sores appear is unknown, but some experts believe that problems with the immune system may be involved. The immune system is the body system that fights disease, bacteria, and viruses. Since canker sores tend to run in families, genetics has been suggested as playing a role in the recurrence of the condition. The American Dental Association (ADA) suggests that fatigue, emotional stress, an accidental bite on the inside of the mouth, a viral infection, an allergic reaction to food, a visit to the dentist, or menstruation may all increase the possibility of developing a canker sore in susceptible patients.

Cold sores (herpes simplex virus): Cold sores are caused by a reactivation of the herpes simplex-1 virus after a period of latency or inactivity, in which a trigger suddenly causes the virus to replicate, resulting in a herpes outbreak. Exposure to sunlight or other ultraviolet light, such as black lights or fluorescent lamps, is a common trigger for the formation of cold sores. Stress on the body due to illness or excessive exercise can weaken the body's immune system and

lead to an outbreak of oral herpes. Common examples of stress or illness include infection, fever, a cold, physical injury, dental surgery, menstruation, medications (including steroids), illnesses (such

as the human immunodeficiency virus (HIV)) that suppress the immune system, eczema, excessive exercise, and emotional stress.

Leukoplakia: Leukoplakia is a condition in which white patches form on the gum, the exact cause of which is unknown. Tobacco use appears to be responsible for most cases of leukoplakia. The majority of individuals who develop leukoplakia are smokers, and most leukoplakic patches either

improve or disappear within a year after stopping smoking. Chewing tobacco and snuff also play a key role. As many as three out of four regular users of smokeless tobacco products eventually develop leukoplakia where they hold the tobacco against their cheeks. Dentifrices containing sanguinarine (a compound found in the herb bloodroot) have been associated with leukoplakia in patients using tobacco products. Other possible causes have been linked to leukoplakia,

including long-term alcohol use; chemotherapy or radiation treatments to the head and neck; Candida albicans (which causes oral thrush); the human papillomavirus (HPV, responsible for genital warts); irritation from rough teeth, fillings, or ill-fitting dentures; and sun exposure to

the lips.

Mucositis: Oral mucositis occurs as a result of both direct toxicity on

the mucosal cells and myelosuppression, a condition in which bone marrow activity is decreased from chemotherapy and radiotherapy, resulting in fewer red blood cells, white blood cells, and platelets. The lining of the gastrointestinal tract (from the mouth to the anus) is

made of epithelial cells, which normally divide and replicate rapidly. Chemotherapy and radiation treatments not only kill cancer cells but also damage epithelial cells, preventing them from regenerating. This damage results in the painful sores characteristic of mucositis.

Oral candidiasis (oral thrush): Candidiasis is an opportunistic infection caused by the fungus Candida albicans. Opportunistic infections occur in individuals who have weakened immune systems. The Candida albicans fungus is found almost everywhere in the environment, which is why most people have small amounts of Candida albicans in their

mouths at any given time. Some common causes of oral thrush include xerostomia (dry mouth) and the use of antibiotics and immunosuppressants, which are any substances that lower the body's immune response.

SIGNS AND SYMPTOMS

Acrodermatitis enteropathica: In infants, the symptoms of acrodermatitis enteropathica generally appear as red and swollen patches

of dry and scaly skin with crusted or pus-filled blisters around the face, the buttocks, and the extremities. Infants also tend to have mouth

ulcers, a red and glossy (wet and shiny) tongue, diarrhea, behavioral changes, and neurologic disturbances. In older children, the most typical symptoms include failure to grow, anorexia (decreased appetite),

swollen skin around the nails, and repeated infections. Additional common symptoms include pinkeye, hair loss (eyelashes, eyebrows, and on the scalp), sensitivity to light, irritability, and depressed mood.

Canker sores: Canker sores appear inside the mouth as ulcers (eroded areas of the oral cavity, marked by tissue disintegration) that are white or gray with a red border. These sores usually develop on the inside of the lips, the cheeks, or the tongue. The lesions usually heal in 7-14 days and tend to recur. In most cases, fever is not present. The

sores can cause sharp pain in the mouth, affecting the patient's ability to eat, drink, or speak.

Cold sores (herpes simplex virus): The symptoms of cold sores are blisters on or around the lips and the edge of the mouth. The first symptoms usually appear within one or two weeks and as late as three weeks after contact with an infected person. In certain people, the virus may stay dormant or inactive for years or may never cause an outbreak at all.

The first symptom that may appear during an outbreak of oral herpes or cold sores may include tingling, burning, or itching in the area around the mouth or nose. This first portion of the outbreak is known as the prodrome stage (or period).

Within a few hours to days, the area may become reddened and develop small, fluid-filled blisters called vesicles. Several of these small blisters may even come together and form one large blister. Cold sore blisters usually break open, weep clear fluid, and then crust over and disappear after a few days.

The patient may experience symptoms including a sore mouth that makes eating, drinking, and sleeping uncomfortable. Other symptoms include fever, sore throat, and swollen lymph nodes in the neck.

Symptoms usually last 7-10 days. Following the active infection, the virus becomes latent (dormant), residing in the nerve cells, and may reactivate later, causing a new outbreak at or near the original site.

Leukoplakia: Leukoplakia can have various appearances, but it typically

first appears as flat, gray or gray-white plaques (sores), usually on the gums or on the insides of the cheeks and sometimes on the tongue. Over weeks or months, leukoplakia can develop into patches with a white color; a thick, rough, or wrinkled texture; and a hardened surface. Sometimes, individuals may also have erythroplakia (raised red lesions or sores, which are more likely to show precancerous changes).

Mucositis: Radiation and chemotherapy may damage the lining of the mouth, resulting in symptoms ranging from slight soreness to mouth ulcers. The sores may appear on any of the soft tissues of the lips or mouth, including the gums and tongue. Other symptoms include a red, shiny, or swollen mouth and gums, blood in the mouth, soreness or pain in the mouth or throat, difficulty swallowing or talking, a feeling of dryness or pain when eating food, and increased or thicker saliva in the

mouth.

Mucositis due to radiation usually appears toward the end of the second

week of treatment, plateaus during the fourth week of radiation, and may persist for 2-3 weeks after treatment is over.

Mucositis due to chemotherapy typically begins 3-5 days after the start

of therapy, peaks at 7-10 days, and slowly subsides over the next week.

Oral candidiasis (oral thrush): Symptoms of oral thrush may develop suddenly. Oral thrush symptoms are usually easy to spot and include white or yellow spots in the mouth, particularly on the tongue and the inside of the cheeks; raised areas in the mouth that bleed and become sore if scraped; a burning sensation in the throat; and difficulty chewing and swallowing.

DIAGNOSIS

The American Dental Association (ADA) recommends visiting a dentist if a mouth sore lasts a week or longer.

Acrodermatitis enteropathica: A zinc deficiency can be diagnosed from a

blood test. Characteristic symptoms such as dermatitis (skin inflammation), hair loss, irritability, and depression may also assist the physician in diagnosing acrodermatitis enteropathica.

Canker sores: Canker sore lesions are unique and usually allow for a diagnosis simply on physical examination, however, a complete medical history of the individual may be needed.

In addition, a doctor or dentist may order the following tests to help confirm the diagnosis and rule out other causes for the ulcers: blood tests; cultures of the lesions to determine if a virus or bacteria are present; and a biopsy of the lesion. A biopsy is the taking of a small piece of tissue from the lesion and examining it microscopically.

Patients with complex aphthosis (constantly having more than three sores) tend to have intestinal or blood diseases, or deficiencies in iron, folic acid, vitamin B6, vitamin B12, or zinc. These patients receive a thorough medical examination and may be referred to a specialist if needed.

Cold sores (herpes simplex virus): Herpes simplex sores may look like canker sores, but usually a dentist or doctor can diagnose canker sores by their shape and size. Cold sores generally appear around edge of the mouth and on the roof of the mouth, while canker sores develop on the soft tissue of the mouth, for example, the inside of the lips or the tongue. Cold sores also cause a lot of pain for a sore that is quite small. A doctor may test for low levels of folic acid or vitamin B12 in the blood if the sores keep returning. Less commonly, a viral culture test (swabbing the sore in order to culture the virus in a lab) or polymerase chain reaction test (which detects herpes DNA) can be used to

assist in diagnosis. The viral culture must be performed within the first 48 hours and before the blister has crusted over.

Leukoplakia: Most often, a dentist diagnoses leukoplakia by examining the patches in the mouth and ruling out other possible causes for the symptoms. To help ensure that no early signs of cancer exist, a dentist may biopsy (remove) a tissue sample for analysis. The tissue is then analyzed in a laboratory using a highly specialized imaging system that allows a pathologist to detect a single abnormal cell among hundreds of thousands of healthy cells. A negative report means no abnormal cells are present. If the report is positive, a dentist is likely to perform another biopsy of a small tissue sample and send it to a laboratory for further analysis.

Mucositis: Diagnosis of mucositis is based on the exhibited symptoms and appearance of the tissues of the mouth following chemotherapy, bone marrow transplants, or radiotherapy. The appearance will be characterized by red burn-like sores or ulcers throughout the mouth.

Oral candidiasis (oral thrush): In most cases, diagnoses of candidiasis

infections can be determined after a physical examination of the sores,

based on their physical appearance and location. If a diagnosis is uncertain, the physician may scrape surface cells of the mouth, or culture a tissue sample from the throat to determine whether the fungus is present. If Candida albicans is present, a positive diagnosis for candidiasis is made.

COMPLICATIONS

Acrodermatitis enteropathica: Without treatment, acrodermatitis enteropathica will lead to death. Supplementation with zinc ensures complete remission.

Canker sores: Canker sores are vulnerable to infection by bacteria in the mouth. Complications of canker sores may include fever, swollen glands, and fatigue. Sores that keep coming back can indicate that important vitamins may be low, especially folic acid or vitamin B12.

The American Academy of Family Physicians (AAFP) recommends that patients should contact their physicians when canker sores are large (greater than one centimeter), last longer than a week, or too painful to allow eating.

Cold sores (herpes simplex virus): The herpes virus may spread from one

area to another on the same person, which is called autoinoculation and

most frequently occurs at the time of primary infection. An example of autoinoculation is ocular herpes, which may lead to serious damage of the eye if left untreated.

In patients who have a compromised immune system, the cold sores may spread to other parts of the face or may infect organs. Less commonly, the virus may cause encephalitis (acute inflammation of the brain), requiring hospitalization and the use of intravenous medications.

Finally, some patients may develop erythema nodosum following a herpes episode. Erythema nodosum is an inflammatory condition in which tender, red nodules form under the skin. Patients suffering from this condition will develop red and painful skin lumps on the front of the legs. Although self-limited (terminating naturally), treatment of the herpes outbreak with antiviral medications may hasten the resolution of erythema nodosum.

Leukoplakia: Leukoplakia usually does not cause permanent damage to tissues in the mouth and frequently goes away once the irritating factors, such as smoking, are removed. Some patches may become inflamed,

however, causing ongoing discomfort.

Oral cancer is the most advanced stage of leukoplakia. Oral cancer most

often occurs in people older than the age of 40. It is often found at late stages, when it is harder to treat. This is because oral cancer is not usually painful, so individuals may not recognize the problem early.

Also, many people do not visit their dentists often enough to find the cancer early. The most common sites of oral cancer are on the tongue, lips, and floor of the mouth.

Hairy leukoplakia, in contrast, is not painful and is not likely to lead to cancer but may indicate the presence of HIV infection or AIDS.

Mucositis: The consequences of mucositis can be mild (needing little treatment) to severe (possibly resulting in fatal complications). Severe

complications of mucositis include hypovolemia (decreased blood volume), electrolyte abnormalities (such as sodium and potassium imbalances), and malnutrition. Other complications from mucositis may include taste loss, nausea, pain, vomiting, diarrhea, and a sore or dry mouth. These factors may make eating difficult. Weight loss may also occur.

Oral candidiasis (oral thrush): If left untreated, oral candidiasis may

progress to esophageal candidiasis, which occurs when the infection spreads to the esophagus, the tube that leads from the mouth to the stomach. Drugs that suppress acid production, such as H2 blockers and proton pump inhibitors, may contribute to fungal infections of the upper

gastrointestinal tract and may predispose some patients to infectious Candida esophagitis.

TREATMENT

Acrodermatitis enteropathica: Although there is no known cure for acrodermatitis enteropathica, zinc supplements taken by mouth daily have

been shown to effectively manage symptoms. The zinc supplementation must be maintained for life. Skin lesions or sores usually heal 1-2 weeks after treatment is started, while other symptoms begin to improve within 24 hours.

Along with zinc supplementation, warm compresses and petrolatum applied

to the weeping and crusting lesions may promote healing of the skin and

alleviate symptoms.