Oral Infections, Ulcers & Blistering Diseases

Viral and fungal infections

Condition	Typical picture
Primary herpetic gingivostomatitis (HSV-1)	Young child, fever, painful gingiva and widespread vesicles that ulcerate; heals in 1–2 weeks
Recurrent herpes	Herpes labialis on the vermilion; intraoral recurrences on keratinized mucosa (hard palate, attached gingiva); antivirals work best in the prodrome
Herpes zoster (VZV)	Unilateral painful vesicles along a trigeminal branch, stopping at the midline
Herpangina (coxsackie A)	Small ulcers on the soft palate and tonsillar pillars, fever
Hand-foot-and-mouth disease (coxsackie A16, enterovirus 71)	Oral ulcers plus hand and foot lesions
Oral hairy leukoplakia (EBV)	Corrugated white lateral tongue in immunosuppression; does not wipe off
Pseudomembranous candidiasis	White curds that wipe off leaving red mucosa
Erythematous candidiasis forms	Denture stomatitis, median rhomboid glossitis, angular cheilitis; treat the denture too

Type	Size and healing	Sites
Minor aphthae	Under 1 cm; heal in 7–14 days without scarring	Nonkeratinized mucosa
Major aphthae	Over 1 cm, deep; weeks to heal; scarring	Nonkeratinized mucosa, often the soft palate and pharynx
Herpetiform aphthae	Many 1–3 mm ulcers that coalesce	Favor nonkeratinized mucosa but can occur anywhere; not caused by HSV
Traumatic ulcer	Heals within about 2 weeks after removing the cause	Lateral tongue, lips, buccal mucosa; biopsy if it does not heal

Recurrent aphthae with genital ulcers and eye inflammation suggest Behçet disease. Consider celiac disease, inflammatory bowel disease, iron, B12 or folate deficiency, and cyclic neutropenia in severe cases.

Disease	Split and target	Direct immunofluorescence	Clinical clues
Pemphigus vulgaris	Intraepithelial, above the basal layer (acantholysis); desmoglein 3 (± 1)	Intercellular IgG ('fishnet' pattern)	Oral lesions often first; ragged erosions, positive Nikolsky sign; potentially fatal without treatment
Mucous membrane pemphigoid	Subepithelial; BP180, laminin 332 and other basement membrane proteins	Linear IgG and/or C3 at the basement membrane	Desquamative gingivitis in older women; eye involvement can scar, so refer to ophthalmology
Erythema multiforme	Immune reaction, often to HSV or drugs	Nonspecific	Sudden ulcers, bloody crusted lips, target skin lesions; young adults
Oral lichen planus (for comparison)	T-cell attack on basal cells (band-like infiltrate)	Shaggy fibrinogen at the basement membrane	Bilateral white striae (Wickham), erosive forms; listed as an oral potentially malignant disorder

Calling palatal and gingival vesicles in an adult 'aphthae': recurrent intraoral HSV favors keratinized mucosa.
Expecting herpetiform aphthae to be caused by herpes virus.
Mixing up the splits: pemphigus is intraepithelial; pemphigoid is subepithelial.
Forgetting the eye referral in mucous membrane pemphigoid.

Pick an answer to see right away whether it is correct and why.

An adult has clusters of small ulcers on the hard palate 3 days after a dental injection there. Most likely diagnosis:
Biopsy shows suprabasilar acantholysis and intercellular IgG on direct immunofluorescence. Diagnosis?
A 60-year-old woman has red, peeling gingiva (desquamative gingivitis) and a scarring eye lesion. The most likely diagnosis is:
A 4-year-old has fever, swollen bleeding gingiva and many ulcers throughout the mouth. Most likely:
Which white lesion wipes off?

0 of 5 answered

Answer key: 1 D · 2 C · 3 C · 4 C · 5 B

Dental School Map · Original study material, written and checked by our team; always confirm clinical decisions against current guidelines.