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Ulcerative
mucositis typically appears in the non-keratinized surfaces of
the oral cavity, for instance the inner surfaces of the cheeks
and lips, the floor
of the mouth, the lateral
and bottom surfaces of the tongue, and the soft
palate. Some studies have also reported a distribution of
these lesions on keratinized surfaces such as the hard palate
and upper surface of the tongue. If ulcerations are noted in these
areas, cultures and/or biopsies should be taken from the lesions
to rule out viral infections or other causes. Redness and/or ulcerations,
ranging from a few millimeters to a few centimeters long, can
appear. Bleeding from the ulcerations is common; however, bleeding
often reflects a severe reduction in a patient's platelet count,
a condition called thrombocytopenia.
Due to the
concurrent loss of white blood cells with thrombocytopenia, bleeding
can result from the mouth, throat and/or along the gastrointestinal
tract. In the past uncontrolled bleeding from the mouth from oral
mucositis was common, but such bleeding is rarely seen today due
to the availability of platelet infusions and better therapeutic
regimens. If blood is seen in the mouth, assessing the source
is important and often difficult.
Other associated
chemotherapeutic complications can appear as ulcerative mucositis,
namely acute graft-versus-host disease (GVHD) in bone marrow transplantation
patients and herpes simplex virus (HSV) infections. Determining
the cause of oral ulcers can be challenging. Culturing or taking
a biopsy of an unusual ulcer is recommended to rule out infections.
The prevalence
of acute GVHD ranges from 18% to 70% of bone marrow patients who
receive marrow grafts from other persons (as opposed to themselves)
(Sullivan
et al., 1983; Hood
et al., 1987). Acute GVHD can present as ulcers, large fluid-filled
blisters (bullae),
or desquamation. (Woo
et al., 1993;Woo
et al., 1997). However, GVHD ulcerative lesions often appear
when the patient's absolute neutrophil count has recovered enough
to indicate the successful integration of the marrow graft. In
addition, other signs and symptoms of acute GVHD typically appear
concurrently in multiple areas of the body, such as the gastrointestinal
tract and skin, suggesting that the oral lesions are GVHD-related.
Herpes lesions can also present as oral ulcers. Prior to the prophylactic
use of the antiviral agent acylcovir for all bone marrow transplant
recipients, herpes was confirmed in 68%-90% of oral lesions (Wade
et al., 1984; Saral
et al., 1981; Gluckman
et al., 1983). Currently, herpes-related mucositis is rarely
seen in patients undergoing bone marrow transplantation. However,
herpetic lesions are often seen in patients undergoing chemotherapy
or radiation treatment.
Diagnosis
of herpes versus mucositis ulcerative oral lesions can be complicated.
Herpetic lesions tend to be seen in both keratinized and non-keratinized
areas intraorally (Woo
et al., 1990). Ulcerative mucositis is predominantly seen
in the non-keratinized tissues as mentioned above. Suspected herpetic
lesions should be cultured because these lesions predispose patients
to secondary infections, which can potentially cause breakthrough
dissemination of the virus causing organ involvement.
Oral manifestations
that can be seen in bone marrow recipients and patients undergoing
chemotherapy or radiotherapy are:
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