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| HEREDITARY – EPIDERMOLYSIS BULLOSA Skin lesions are always present; Nikolsky’s sign often present; mouth opening may be restricted due to scarring. Lesions are congenital or begin at an early age; patient frequently has a familial history. |
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| MYCOTIC – CANDIDOSISv(CANDIDIASIS) Diffuse mucosal erythema; burning or pain may be present; ulcers are rarely present; lymphadenopathy is rare. Patient often has predisposing factors: antibiotics, immunosuppression. |
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| AUTOIMMUNE Slow onset; chronic lesions; exacerbations & partial remissions; lesions do not heal in a predictable period of time; lymphadenopathy is rare. |
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| Mucous membrane pemphigoid (cicatricial pemphigoid; benign mucous membrane pemphigoid) | Erythematous attached gingiva; vesicles sometimes observed; Nikolsky sign may be present; skin vesicles & ulcers may be present. |
| Bullous pemphigoid | Skin vesicles, bullae & ulcers are always present; occasional oral vesicles & ulcers. |
| Pemphigus | Mucosal vesicles & ulcers in any location usually precede skin lesions; Nikolsky sign may be present. |
| Lupus erythematosus | Nonspecific mucositis & ulcers are sometimes present but are associated with skin lesions. Oral lesions: white epithelial striae with submucosal erythema (lichenoid lesions). Multiple organ system disorders: erythematous skin rash, photosensitivity, arthritis, nephritis, neurologic disease; anemia, leukopenia, thrombocytopenia. |
| VIRAL Acute onset; multiple lesions; systemic manifestations (malaise, fever, diarrhea, lymphadenopathy, lymphocytosis) often present; vesicle stage is present in all except mononucleosis. |
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| Primary herpes | Vesicles & ulcers may be present anywhere in the oral cavity, pharynx, lips or perioral skin; gingiva is edematous & erythematous; lymphadenopathy is common; malaise, fever & diarrhea in some cases. |
| Recurrent herpes | Occurs on sun-exposed surfaces of lips; intraorally occurs on keratinized mucosa (dorsum of tongue, hard palate, attached gingiva); usually recurs in same location; heals in a predictable period of time for each patient. |
| Varicella (chickenpox) | Crops of pruritic papules, vesicles, ulcers on trunk spreading to arms, legs & face; mild malaise, fever & lymphadenopathy; occasional oral ulcers. |
| Herpes zoster (shingles) | Prodromal pain followed by vesicles & ulcers in the distribution of a sensory nerve; unilateral lesions; postherpetic neuralgia may occur. |
| Herpangina (Coxsackievirus A) | Vesicles & ulcers in posterior oral cavity & pharynx; may have mild systemic manifestations. |
| Hand, foot and mouth disease (Coxsackievirus A) |
Vesicles & ulcers of oral & pharyngeal mucosa; vesicles & macules on hands and feet; mild systemic manifestations. |
| Rubeola (measles) | Fever, conjunctivitis, photophobia, cough, nasal discharge; oral vesicles (Koplik spots); erythematous maculopapular skin rash on face spreading to trunk & extremities. |
| Epstein-Barr virus | Infectious mononucleosis Generalized lymphadenopathy; splenomegaly; hepatomegaly; palatal petechiae; erythematous oral & pharyngeal mucosa; occasionally mucosal ulcers; no vesicular stage. |
| IDIOPATHIC Each disease must be considered as a separate entity. |
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| Aphthous ulcers | Abrupt onset of recurrent ulcers on nonkeratinized mucosal surfaces; individual ulcers heal in a predictable period of time which is variable for each patient; may be menstrually related; familial history common; “herpetiform” aphthae refer to multiple crops of small aphthous ulcers; “major” aphthae are deeper, longer lasting and more frequent ulcers which often heal with scarring. |
| Erosive lichen planus | Erythematous mucosal lesions usually with areas of ulceration; often bilateral distribution; white epithelial striae at edge of erythematous areas; atrophy of filiform papillae may be seen; chronic course. |
| Medication-induced mucositis | A variety of drugs cause mucosal lesions that do not appear to be allergic in nature; mucosal lesions consists of ulcers and erosions occurring on both keratinized & nonkeratinized mucosal surfaces. |
| Contact stomatitis | Burning, pain, ulcers, erosions, erythema sometimes covered with shaggy hyperkeratosis. Most commonly secondary to cinnamon flavoring. |
| Erythema multiforme | Sudden onset of diffuse mucosal ulcers involving buccal & labial mucosa; sometimes recurrent with variable periods of remission; skin lesions present “iris” or “target” appearance on palmar & plantar surfaces; lymphadenopathy is rare. |
| Erythroplasia (erythroplakia): epithelial dysplasia, carcinoma in situ, superficially-invasive squamous cell carcinoma | Asymptomatic, persistent, erythematous, velvety, focal to diffuse mucosal areas; more common in heavy consumers of alcohol. |
