Differential diagnosis
Burning Mouth Syndrome

Author: Alberto Iuso
Date: 29/05/2007


Differential Diagnosis
Oral Herpes
Herpes labialis is an infection caused by the herpes simplex virus. It leads to the development of small and usually painful blisters on the skin of the lips, mouth, gums, or lip area. These blisters are commonly called cold sores or fever blisters.
Herpes labialis is an extremely common disease caused by infection of the mouth area with herpes simplex virus, most often type 1. Most Americans are infected with the type 1 virus by the age of 20.
The initial infection may cause no symptoms or mouth ulcers. The virus remains in the nerve tissue of the face. In some people, the virus reactivates and produces recurrent cold sores that are usually in the same area, but are not serious. Herpes virus type 2 usually causes genital herpes and infection of babies at birth (to infected mothers), but may also cause herpes labialis.
Warning symptoms of itching, burning, increased sensitivity, or tingling sensation may occur about 2 days before lesions appear.

Skin lesions or rash around the lips, mouth, and gums
Small blisters (vesicles) filled with clear yellowish fluid
Blisters on a raised, red, painful skin area
Blisters that form, break, and ooze
Yellow crusts that slough to reveal pink, healing skin
Several smaller blisters that merge to form a larger blister
Mild fever (may occur)

Pemphigus is an autoimmune disorder that causes blistering and raw sores on skin and mucous membranes. As with other autoimmune disorders, it is caused when the body's defenses mistake its own tissues as foreign, and attack the cells. Pemphigus is derived from the Greek pemphix, meaning bubble or blister.
If not treated, pemphigus is fatal, due to overwhelming systemic infection. The most common treatment is the administration of oral steroids, especially prednisone. Recently, there has been great promise of surviving some forms of pemphigus (especially PNP) by using a pooled blood product known as gamma globulin or IVIG. Mild cases sometimes respond to the application of topical steroids. All of these drugs may cause severe side effects, so the patient should be closely monitored by doctors. Once the outbreaks are under control, dosage is often reduced, to lessen side effects.

If paraneoplastic pemphigus is diagnosed with pulmonary disease, a powerful cocktail of immune supressant drugs is sometimes used in an attempt to halt the rapid progression of bronchiolitis obliterans. Some drugs used include solumedrol, cyclosporin, azathioprine, and in rare instances, extremely controlled use of thalidomide in eligible patients. Immune phoresis procedures are also a possible treatment.
If skin lesions do become infected, antibiotics may be used for treatment. In addition, talcum powder is helpful to prevent oozing sores from adhering to bedsheets and clothes.

Squamous cell carcinoma

Squamous cell carcinoma of the head and neck is most commonly associated with the use of alcohol and tobacco. The risk for oral cancer is additive and is 15 times greater than in those who neither smoke nor drink. In squamous cell carcinoma, mutations in the p53 gene correlate with drinking and smoking habits. Some 15% of patients have a viral etiology. Epstein-Barr virus (EBV) has been implicated in the development of nasopharyngeal carcinoma. Human papillomavirus infection is another factor implicated in the carcinogenesis of upper aerodigestive tract tumors. In particular, human papillomavirus-16 can be isolated in 36% of oral cavity cancers.

Environmental exposures to paint fumes, plastic byproducts, wood dust, asbestos, and gasoline fumes have been implicated as risk factors. Gastroesophageal reflux disease is now thought to be a significant risk factor for cancer of the larynx and especially the anterior two thirds of the vocal cords. Irritation from poorly fitting dentures also has been implicated.


Squamous cell carcinoma is thought to arise from keratinizing or malpighian epithelial cells. The hallmark of squamous cell carcinoma is the presence of keratin or “keratin pearls” on histologic evaluation. These are well-formed desmosome attachments and intracytoplasmic bundles of keratin tonofilaments. The term epidermoid can be substituted for squamous.

Morphologically, it is variable and may appear as plaques, nodules, or verrucae. These in turn may be scaly or ulcerated, white, red, or brown. Verrucous carcinoma has a more favorable prognosis because of infrequent nodal and distant metastasis.

Clinical presentation

Squamous cell carcinomas usually begin as surface lesions with erythema and slight elevation. These lesions are termed erythroplasia and deserve biopsy. These early red lesions are asymptomatic and may be either carcinoma in situ or invasive carcinoma. One third of lesions are pure white; they are known as leukoplakia but only 10% of them are carcinoma in situ or invasive carcinoma. The most common sites for squamous cell carcinoma are the floor of the mouth, the tongue, soft palate, anterior tonsillar pillar, and the retromolar trigone. Tender, painful lesions usually are suggestive of perineural invasions. When lesions become palpable masses, symptoms such as a vague persistent sore throat or ear infection occur.

In more advanced cases, dissemination to ipsilateral submandibular and jugulodigastric nodes is common, and the patient may present with a mass in the neck. When lymph node or remote bone and organ metastases are associated with an early oral primary lesion, often a second, more advanced primary upper aerodigestive or lung cancer is responsible for the metastases.

Oral Candidiasis

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