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PART II
Soft Tissue Lesions
hand, if removable white plaques filled with yeast fOnTIS and pseudohyphae are present, the diagnosis is primary or secondary candidiasis. Because its oral lesions are also covered by pseudomembranes, gangrenous stomatitis may be confused with candidiasis. Its plaques or pseudomembranes are not raised above the mucosa, however, but cover an ulcerating lesion that may extend to bone. Also its pseudomembranes are usually a dirty gray color, in contrast to the whiteness of those that develop in candidiasis. Gangrenous stomatitis may carry a much graver prognosis than candidiasis, since the patient may be seriously ill with an uncontrolled debilitating disease; however, candidiasis also affects terminally ill patients. Recurrent herpes simplex may resemble pseudomembranous candidiasis. Occasionally candidiasis demonstrates some examples of roundish, white lesions the same size as clusters of recently ruptured herpes simplex vesicles. Herpes lesions are usually more painful. Smears would show candidal organisms. Chemical burns in some instances closely mimic candidiasis. The distinction is usually made by an accurate history, disclosing that a medicament has been applied to the mucosa.
Management The management of patients with oral candidiasis is twofold: (I) attempts to identify, correct, or eliminate predisposing or precipitating factors and (2) antifungal therapy. Any oral lesion with surface debris may harbor candidal organisms even to the extent that a secondary candidiasis may become established. Nystatin treatment in such cases produces some improvement, but full remission must await successful treatment for the primary lesion. The treatment of candidiasis is discussed in detail in Chapter 5.
The ulcers are usually deep craters with a white necrotic surface (Fig. 8-48). In most instances they commence as small mucosal injuries that become chronically infected because of the decreased resistance of the patient. These lesions are discussed and illustrated in Chapter II.
DIFFUSE GANGRENOUS STOMATITIS Diffuse gangrenous stomatitis is also an oral disease in which a pseudomembrane is formed. Its cause is almost identical to that of ANUG, but it occurs in extremely debilitated patients. It must be differentiated from localized gangrenous stomatitis (cancrum oris or noma), a single localized and very destructive lesion (Fig. 8-49) seldom encountered in the United States. Griffin, Bach, Nespeca. et aJ 99 described two cases that occurred in young children in the South Pacific.
Features Diffuse gangrenous stomatitis is usua]Jy found in patients with severe debilitating diseases, such as advanced diabetes, uremia, leukemia, blood dyscrasias, malnutritional states, or heavy metal poisoning. The patient complains of sensitive or painful oral lesions and a very unpleasant odor. The lesions are multiple, affecting several mucosal surfaces, and are surrounded by a thin, inflamed margin. The lesions are covered by a dirty gray to yellow pseudomembrane that can be readily removed. leaving a raw, bleeding, painful surface. They may be elliptic. linear, or angular. A tender to painful cervical lymphadenopathy is usually present.
Differential Diagnosis Differential aspects of diffuse gangrenous stomatitis are discussed in the section on the differential diagnosis of candidiasis.
NECROTIC ULCERS OF SYSTEMIC DISEASE
Management
Necrotic ulcers may occur in debilitating systemic diseases such as leukemia, sickle cell anemia, and uremia.
Local treatment of diffuse gangrenous stomatitis is similar to the regimen described for ANUG: systemic amoxi-
Fig.8-48. Necrotic ulcer on the palate of a patient with mycosis fungoides. (Courtesy M. Sneed, Los Angeles.)
Fig. 8-49. Noma on the buccal mucosa of a patient terl1linall) ill with acute myelogenous leukemia. (From Weinstein RA. et al: Oral Sltrg 38:10-14,1974.)