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Necrotizing ulcerative gingivitis, often caused by an infection of both spirochetes and fusiform bacilli, is common in young adults under stress (classically at examination time). Underlying systemic diseases may also predispose to this disorder. Clinically, there is painful acute gingival inflammation and necrosis, often with bleeding, halitosis, fever, and cervical lymphadenopathy. In addition to altering or removing, if possible, underlying factors and correcting dietary inadequacies, warm half-strength peroxide rinses and oral penicillin (250 mg three times daily for 10 days) may help. Dental gingival curettage may prove necessary.
Necrotizing ulcerative periodontitis is discussed later in this chapter in the section on AIDS.
Aphthous ulcers are very common and easy to recognize. Their cause remains uncertain. Found on nonkeratinized mucosa (eg, buccal and labial mucosa and not gingiva or palate), they may be single or multiple, are usually recurrent, and appear as painful small (usually 1–2 mm, but sometimes 1–2 cm) round ulcerations with yellow-gray fibrinoid centers surrounded by red halos. The painful stage lasts 7–10 days; healing is completed in 1–3 weeks.
Treatment is nonspecific. Topical steroids (triamcinolone acetonide, 0.1%, or fluocinonide ointment, 0.05%) in an adhesive base (Orabase Plain) do appear to provide symptomatic relief. A 1-week tapering course of prednisone (40–60 mg/d) has also been used successfully.
Large or persistent areas of ulcerative stomatitis may be secondary to erythema multiforme or drug allergies, acute herpes simplex, pemphigus, pemphigoid, bullous lichen planus, Behcet's Behçet's disease, or inflammatory bowel disease. Squamous cell carcinoma may occasionally present in this fashion. When the diagnosis is not clear, incisional biopsy is indicated.
Herpetic gingivostomatitis is common, mild, and short-lived and requires no intervention in most adults. In immunocompromised individuals, however, reactivation of herpes simplex virus infection is frequent and may be severe. Clinically, there is initial burning, followed by typical small vesicles that rupture and form scabs. Acyclovir (200–800 mg five times daily for 7–14 days) may shorten the course and reduce postherpetic pain. Differential diagnosis includes ulcerative stomatitis (see above) as well as erythema multiforme, syphilitic chancre, and carcinoma. Coxsackievirus-caused lesions (grayish white tonsillar and palatal ulcers of herpangina or buccal and lip ulcers in hand-foot-and-mouth disease) are seen more commonly in children under age 6.
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