Sores, Lumps & Bumps

Thrush is a common problem for infants since their immune systems are not yet fully developed. In healthy adults, however, it happens only rarely, and usually is an indication of a lowered immune response. Often it is due to illnesses such as general viral infections or stress related fatigue. It is characterized by creamy white, soft plaques that are easily scraped off the mucosa (the lining of the mouth) revealing a red, inflamed patch underneath. This type is seen in the picture to the right. It is easily treated with topical antibiotics like Nystatin.

The image to the left shows pharyngeal candidiasis. The pharynx is the technical name for the throat. This form of yeast infection is seen often in persons using inhaled steroid medications for the treatment of asthma. It is also seen in AIDS patients due to their depressed immune functions. Oral and pharyngeal candidiasis are not contagious.

Angular Cheilitis

Angular cheilitis is a very common fungal infection of the corners of the lips. It happens all the time to healthy people who tend to have moist lips, especially in the cold winter months. This condition is caused by a persistent fungal infection, and left untreated, may remain active for many months. It generally looks like a reddened, dry area at the corners of the lips. It is easily treated with Nystatin cream which is simply an antibiotic that kills the fungus. If the patient is prone to psoriasis, sometimes a combination of Antifungal and a steroid (Mycolog--nystatin and triamcinolone, or Vytone--iodoquinol and hydrocortisone) will work better to relieve the condition. Angular cheilits is not contagious.

Disorders caused by viruses

Hairy Leukoplakia

Hairy leukoplakia is a white, corrugated or "hairy" "coating" on the lateral borders of the tongue. It is one of the relatively few conditions seen in the oral cavity which is associated almost exclusively with AIDS. Unlike Thrush, it is not easily scraped off. It is painless, but patients occasionally complain of its appearance and texture. It is caused by the body's reaction to the Epstein-Barr virus (responsible for Mononucleosis), and can be eliminated with a viral antibiotic like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®).

This condition is rarely seen in patients not infected with HIV. However, some healthy patients may develop a "callous" on the lateral borders of the tongue due to the nervous habit of continually scraping the tongue over the teeth. This can lead to embarrassment if the dentist suggests an AIDS test to a person who believes such a suggestion is an insult! It is never meant as a value judgment. Hairy Leukoplakia is not contagious.

Herpes Zoster

Herpes Zoster (better known as shingles) is caused by the same virus that causes Chicken Pox. Herpes zoster "hides out" in a somatic nerve branch after the initial Chicken Pox infection (which usually happens in childhood), and flares up again later in life when the immune system begins to fail. Shingles is common in otherwise healthy elderly persons. It generally does not occur in younger people unless they are concurrently infected with the AIDS virus. The distribution of the rash on the body is the key to the diagnosis of shingles, and distinguishes the herpes zoster virus from other forms of herpes viruses. The distribution of the rash caused by herpes zoster in shingles is almost always on one side of the body, and is confined to the distribution of a single nerve root. The skin surface distribution of each spinal or cranial nerve is called a dermatome. The image on the left above shows a rash which is confined to the dermatome defined by the third branch of the trigeminal nerve. It is outlined in blue to make it easier to see. Click the image to see larger images, as well as a great deal more on the concept of somatic dermatomes. Shingles infections are quite painful, and they generally go away after four or five weeks, but shingles may reoccur again at a later date. It frequently leaves those so afflicted with "postherpetic neuralgia" (PHN), which is severely sensitive skin, well after the infection.

The image below shows the distribution of the herpes zoster rash from the frontal aspect, this time confined to the distribution of the first and second branches of the trigeminal nerve. Note the sharp delineation between the affected side and the unaffected side in the forehead and nose regions, which corresponds to the distribution of the first branch. The second branch, corresponding to the region below the eye is billaterally (both sides) affected. This image is presented compliments of Dr. Jonathan D. Trobe, MD at the University of Michigan.

In the mouth, it looks very much like a typical intraoral herpes simplex infection. It is, however, identified by its distribution. It is limited to one side of the affected organ. The image to the right shows the Herpes zoster virus infecting half of the upper posterior palate. It is easy to confuse Herpes zoster with Herpes simplex which may occur in the same distribution purely by chance. While the Herpes Zoster virus is contagious, Shingles, surprisingly is not. Since a large percentage of the population already has been exposed to Chicken pox, most people harbor an immunity, and the probability that anyone will develop this disease depends more on the state of their immune system than on recent exposure to the virus.

Herpes Simplex (the "cold sore" or "fever blister" virus)

Herpes Simplex (type I) is the virus that causes cold sores (herpes labialis) in normal, healthy adults. The image at the right shows a typical cold sore, sometimes called a fever blister due to its propensity to appear when the patient has a cold or other febrile (fever causing) illness. This is another bug that, like Shingles, tends to "hang out" in a nerve root for the life of the patient after the initial infection, which often occurs in childhood. Once infected, the patient remains infected for life. The virus remains dormant inside the nerve root most of the time until the patient suffers an illness or other problem which lowers his immune response. The virus takes advantage of the drop in immune response to flare up in the typical cold sore seen in this image. Click the image above for many more images of herpes infections.

This image is what the initial infection may look like when a child, or young adult is first infected with the Herpes Simplex virus. This is called "Primary Herpes stomatitis", and as you can see, it can look quite severe with blisters both inside and outside the mouth. ("Stomatitis" means inflammation of the entire mouth.) The patient is quite sick, but this primary infection will disappear after 10-14 days with rest and lots of fluids. In healthy people, this infection happens only once in a lifetime. Later in life, the presence of the virus only becomes apparent whenever an "ordinary" cold sore appears.

Whenever an adult appears in a clinic with a case of Primary Herpes Stomatitis, this infers a severely depressed immune response, and the dentist might consider referring the patient to a physician for diagnosis of an underlying disorder. Adults presenting with severe herpes stomatitis should consider being tested for HIV. It must be remembered, however, that a primary herpes stomatitis can happen at any time of life if the patient has never before had a cold sore. Click on the image to see larger views of this condition.

Intraoral Herpes

Herpes simplex blisters can sometimes occur in the oral cavity on tissues not generally associated with cold sores. They always happen on tissue that is firmly bound down to underlying bone, such as the gums immediately around the teeth or on the roof of the mouth. As you can see, the appearance of this infection in the mouth can easily be confused with Herpes Zoster (shingles), especially if it occurs on only one side of the mouth. The viruses are closely related, and the blisters in the oral cavity can look identical.

The presence of this type of infection in the mouth does not indicate the presence of HIV, although it is more common in AIDS patients than in the non-HIV population. This can happen to anyone who harbors the Herpes Simplex virus. Left alone, provided the patient is not immunologically compromised, it disappears in 10 to 14 days. The herpes simplex virus is very contagious and if one person in a family develops a cold sore, then others in the family may develop one as well.

New antibiotics like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) are effective in suppressing the Herpes virus and will generally alleviate the symptoms within a fairly short time. This applies to all of the manifestations of herpes mentioned in this section. Unfortunately, the anitbiotics do not often "cure" the disease since the virus continues to remain in an inactive form inside a nerve root waiting for another chance to cause an outbreak.

A Note on Genital Herpes

Herpes Simplex type I (HSV-1) prefers to infect the face and oral cavity. It is the virus most responsible for traditional cold sores and primary herpes stomatitis. There is, however a second variety of Herpes that prefers to infect the genital areas. Herpes Simplex Type II (HSV-2) is called "genital Herpes" because of its venereal (sexually transmitted) qualities. Both varieties produce similar lesions, the difference between them being their site specific preferences. Both establish latency (take up permanent residence) in nerve roots and once established, tend to cause occasional outbreaks with active lesions (sores) in areas of the body serviced by that particular nerve root. HSV-1 prefers to live in the trigeminal nerve root where it causes lesions in the oral cavity and on the face. HSV-2 takes up residence in the sacral ganglion at the base of the spine where it may cause genital lesions (see the dermatome chart on the Herpes zoster page).

Even though each type has site specific preferences, the viruses are genetically similar and can take up residence in nerve roots in other parts of the body, including in each other's territory. Outside of their own home territories, however, neither virus is especially virulent, and rarely cause recurrent outbreaks.

HSV-2 causes approximately 90% of all cases of genital herpes. Genital herpes caused by HSV-1 is generally much milder than that caused by HSV-2. HSV-1 is usually transferred to the genital area by direct oral/genital contact, although the virus is present in the saliva of infected individuals. Thus the use of saliva as a lubricant can, in fact, transfer HSV-1 to the genital area. HSV-1 is found in only about 10% of all cases of genital herpes, however most people infected with HSV-1 in the genital area have few, if any, outbreaks after the initial episode. HSV-2 prefers to live in this area and causes a much more virulent infection there.

On the other hand, HSV-1 causes almost all cases of oral and facial herpes. Oral herpes caused by HSV-2 almost never reoccurs, except in immunocompromised patients.

For more on this subject, visit this page.

Neoplasms (tumors, or "growths")

Human Papillomavirus lesions (warts)

Warts are caused by a virus. In the oral cavity, they tend to be somewhat flatter than the type occurring on hands, but if they are dried with air, the tiny projections characteristic of regular warts become evident. The causitive agent is the Human Papillomavirus (HPV). These growths generally are not painful. They may be removed using lasers, cautery or cold steel blades. A majority of these lesions have not consequences beyond the primary papilloma. Some, especially toward the back of the mouth or throat may have more serious consequences discussed below. HPV is contagious.

There are about 200 different strains of HPV. Most strains are relatively harmless, or may cause papillomas like the one in the image above. Some strains of HPV cause genital warts and are now known as the cause of cervical cancer (cancer of the uterus) as well as anal, vulvar and penile cancers. Although there are eighteen strains with serious pathological consequences, one strain in particular, HPV-16 is quite dangerous in the oral cavity. It is a major causative agent in oral cancers, and is transmitted to the oral cavity via vigorous oral/sexual contact (oral sex). As a result of the stark increase in promiscuous sexual activity since the late 1960's, this strain of HPV is increasingly problematic, and seems to account for the serious rise in the incidence of oral cancers in younger people, many of whom do not smoke or drink regularly. For much more on this subject, please see my page on Oral Cancer.

Five strains of HPV cause oral papillomas. These include 6, 7 11, 16 and 32. Note that young persons who contract oral papillomas, even those infected with HPV-16, will probably clear the infection eventually if their immune systems are not adversely affected by other chronic diseases or lifestyle issues like drug or alcohol addictions.

Because HPV-16 is associated with vigorous sexual oral/genital contact (oral sex), most of the "warts" associated with this strain would most likely occur in the back of the oral cavity, toward the back of the throat, around the tonsils, on the soft pallate, at the base and sides of the tongue, etc. They will rarely be found toward the front of the mouth like the one pictured above. HPV-16 is NOT transferred by "ordinary" kissing, but may be transmitted by vigorous open mouth deep (French) kissing.

There is a saliva test that a dentist can perform that can diagnose hidden cases of HPV. Dentists interested in offering this service to their patients can visit the website of OralDNA Labs to learn about this simple and accurate process.

Kaposi's Sarcoma (KS) (pronounced "cap-o-zeez")

Kaposi's Sarcoma is a tumor composed of numerous tiny blood vessels. It tends to be dark red or deep purple. It may be flat, or a swollen mass. These growths are not generally painful unless secondarily infected by another type of Herpes or bacteria. Thus good oral hygiene is important in the management of these tumors if they occur in the mouth.

Kaposi's occurs most frequently on the skin, although tumors can occur in the gastrointestinal tract and mouth. In the oral cavity, the lesions occur mostly on the palate (the roof of the mouth). Although they are technically a form of cancer, there is evidence that they are, in fact the result of a secondary infection with Herpes virus type VIII. This virus is found in high concentration in the saliva of infected individuals and can cause Kaposi's Sarcoma only in patients with very compromised immune systems. Some recent research has shown that this virus is transferred through deep kissing.

Kaposi's tumors are seen almost exclusively in gay men with AIDS. The occurrence of one of these lesions anywhere on the body of a young man is indicative of the presence of HIV. Kaposi's is infrequent in women, even women with AIDS. It is also rare in men who have contracted AIDS via intravenous drug use. It is not known why women and heterosexual males with AIDS do not generally succumb to Kaposi's sarcoma, although there is probably an association between the gay male lifestyle and the transfer of the herpes type 8 virus. These lesions occur as the initial manifestation of AIDS in approximately 11% of patients.

Prior to the AIDS epidemic, they were seen (rarely) only on the lower extremities of elderly men. They probably occur in elderly men because of age related immune depression. The reason for their appearance in elderly men and not in women may also be associated with lifestyle issues.

For more information on HIV and AIDS, click here to be directed to a page with statistics, diagnostic criteria and the history of the epidemic. You will also find a repeat of the images seen on this page with more specific information on how they relate to AIDS patients.

Lymphoma (lymphatic cancer)

Non Hodgkin's Lymphoma (NHL) is a cancer that starts in a lymph node and spreads to other areas of the body through the lymphatic system and the blood vessels. Prior to the AIDS epidemic, NHL generally effected older individuals (average age 67), however the incidence of NHL has increased substantially in younger persons since the beginning of the AIDS epidemic. Lesions (abnormalities) like those in the image to the right, especially in a younger person, may be the first indication that a patient has HIV, although it is usually accompanied by a generalized lymphadenopathy (swelling of lymph nodes all over the body). A suppressed immune response is a strong factor in the development of NHL, however persons with no history of immunosuppression (or HIV) may contract the disease. There is some evidence that one or more secondary viruses may bear the responsibility for the actual disease, the Epstein-Barr (Mononucleosis) virus once again being a prime suspect. Treatment for this condition usually involves chemotherapy and Radiation therapy. Oral lymphoma can happen any place in the oral cavity. It generally begins as a non specific swelling of the oral tissues in a localized area.

Bacterial diseases of the gums

Periodontal Disease

Periodontal disease is presented in this section as an aid to those who come here looking for images of gum problems they may have noticed, and do not know where to find information. This site contains two entire pages devoted to periodontal disease, including one that explains the causes of periodontal disease and one on how it is treated. Periodontal disease is caused by poor oral hygiene. This site includes a page on correct techniques of oral hygiene that can prevent and even reverse periodontal disease.

Gingivitis

Gingivitis is caused by a chronic buildup of plaque around the teeth and is characterized by a red, sometimes swollen appearance of the gums immediately around the necks of the teeth. It is easily cured by good oral hygiene, but left untreated, it generally leads to periodontal disease and eventual loss of the teeth. Gingivitis is not contageous.

Periodontal disease

Outright periodontal disease may effect a single tooth, or any number of teeth. It begins after about the age of 25, and becomes serious between the ages of 35 and 50. Periodontal disease is painless in its early stages. It is the outcome of a lifetime of poor oral hygiene, and begins with simple gingivitis. In periodontal disease, the gums recede down the roots of the teeth, and the teeth appear to be longer than normal (click on the image above to see more about this image). Since the bone that maintains the teeth is effected by periodontal disease, the teeth become loose, and eventually painful. Periodontal disease is not contagious.

Halitosis

Bad breath is a chronic problem for persons with periodontal disease. However, periodontal disease is not the only cause of bad breath, a I have written an entire page devoted to the various causes and treatment of bad breath.

Acute Necrotizing Ulcerative gingivitis (trench Mouth)
Acute Necrotizing Ulcerative Gingivitis is often called Trench Mouth. In ANUG, the gingiva immediately surrounding the teeth becomes necrotic (dead). ANUG is often found in people with poor oral hygiene who are either ill or under extreme physical or emotional stress. (It was named "trench mouth" because it was common in soldiers who fought in the trenches during world war I. These men were certainly under extreme physical and emotional stress, and had little opportunity to brush their teeth.)

ANUG, being a bacterial infection, is very easily treated by gentle cleaning of the teeth and irrigation of the affected gums with 3% hydrogen peroxide. The bacteria that take advantage of a patient's run-down condition tend to be anaerobic which means that they die in the presence of oxygen. Hydrogen peroxide liberates oxygen (hence the bubbles) when it is exposed to blood, and the oxygen acts as an antiseptic and speeds healing of the damaged gum tissue. The patient is sent home with a prescription for Penicillin and instructions on cleaning the teeth to prevent further problems. It is essential that the patient return to the dentist after the initial infection for a professional cleaning to avoid a recurrance of the disease. ANUG is not contagious.

Dentists today rarely see cases of ANUG, however the disease is making a comeback in communities in which there is a lot of drug addiction. It is especially prevalent in populations of methamphetamine addicts and is a part of the syndrome now known as Meth Mouth.

Acute Necrotizing Oral Stomatitis
This is a sight we never see except in a hospital setting. This man's mouth is being eaten alive by the same bacteria that his immune system would ordinarily have no problem keeping at bay if it were functioning normally. The difference between a dead body and a live one from the point of view of everyday environmental bacteria is a functioning immune system. AIDS attacks the immune system, and unless the disease and the bacteria can be kept at bay by modern drug therapy, the human body has no defense against parasitic bacteria and viruses.

Geographic tongue
This condition is characterized by the disappearance of the filiform papillae from irregular patches on the top surface of the tongue. Then, the patches "heal" up and reoccur on another part of the tongue at a later date. This process keeps going on and on over time, and one can see lesions in varying stages of healing over large expanses of the tongue. No one knows why some people get this condition. It is thought to be an oral form of psoriasis (a common skin condition). Patients who live with this problem frequently complain of pain on eating sharp foods. Serious outbreaks can be treated with topical application of steroid gels. Otherwise it is not treated. It is not a contagious condition. Recently, it has been noted that this condition may be seen more frequently in AIDS patients, however the presence of geographic tongue certainly does NOT mean that the patient has AIDS. The reason that it may be more prevalent in persons with HIV is that the immune system deficit seen in AIDS patients may lead to an increase in dermatological abnormalities such as unusual forms of psoriasis. Click the image on the right for a larger view.