NONSPECIFIC MEMBRANOUS STOMATITIS

LESTER RICHARD eAHN,'" D.D.S., NEW YORK, N. Y.

THE following ease records a condition rarely described in either dental ormedical literature.The patient was a man about sixty-five years old, who first complained of a

pain in the region of the mandibular left second molar, which was acting as anabutment for a sanitary stationary bridge. He consulted his dentist who claimedthat an occluded pocket hindered drainage. This was curetted without bring­ing relief, and the patient, noticing small ulcers on his gum, sought the adviceof his physician. The latter, after making urine and blood analyses, and mor­phologic examination of smears, diagnosed the condition as trench mouth.

The lesions were treated daily with a dye, presumably methylene blue orgentian violet. For home use sodium perborate was prescribed, in a proprietaryvariety in the morning as a mouth wash and in the straight form as a pasteapplied to the gums in the evening. This regimen was followed for a weekwithout much improvement. The physician then advised radiographs of theteeth, and the patient was told that pockets were maintaining the infection andthat he should have them treated. It was at this time that I was consulted.

The following picture was presented. On the gum beneath the sanitarybridge and in the region of the mandibular left molal' were a number of smallulcers. These had a yellow center, surrounded by a red halo. In the area ofthe maxillary left cuspid and the first bicuspid, at the labiogingival fold, therewas a yellowish membranous patch. Palatally at this point there was somegingival irritation. Another membranous patch was present at the bucco­gingival fold in the molar area of the maxillary right side. The membraneswere removed without much difficulty and left raw surfaces. There was noulceration of the interdental papillae, so characteristic of fusospirillary infec­tions. Smears made from the membranes were negative for the latter condition.Pus cells and a few cocci were seen. No pockets were found about the teeth,with the possible exception of the original one, mesial to the mandibular leftsecond molar. Here the gum seemed to hug closely about the root , and I didnot care to probe it. That the condition was not due to the Vincent conglom­erate of organisms was amply proved by the clinicalpicture, the distinctly nega­tive smear, and the lack of results following intensive anti-Vincent treatment.

Since the treatment that he was receiving proved to be of no avail, somemodification was made. The perborate at night was dispensed with, and on hisdaily visit the mouth was sprayed with a very mild chromic acid solution. Occa­sionally the lesion was touched with a pigment.

This treatment was followed for another week with little change in thecondition. The ulcers under the bridge were slightly improved, while the labial

·Associate Professor and Ch airman of Division ot Oral Pathology, Columbia University,

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870 Lester Richard Cahn

and buccal fold lesions seemed to take on a more exudative character. Thereappeared to be a yellowish mueouslike exudate on the surface. A smear wasagain made and proved to consist chiefly of pus cells and a goodly number ofwhat morphologically would be streptococci (Fig. 1). Cultures showed almostan entire predominance of streptococci of the viridans type with a few coloniesof Staphylococcus aureus.

About this time I found a reference! to a somewhat analogous condition.In the article Hiller reported five cases of a membranous pharyngitis that spreadto the mouth and had oral characteristics very much like those described. Amixture of crystal violet, brilliant green, alcohol and water was suggested asalmost a specific remedy. I tried an aqueous solution of brilliant green alone.In forty-eight hours the lesions had practically disappeared, and the conditionwas entirely cured after the second application.

Fig. I.-Photomicrograph of smear made from the gingivolabial fold lesion of upper left cuspidarea. Note pus cells and the preponderance of streptococci.

DISCUSSION

When one mentions the descriptive adjective "membranous" in conjunc­tion with gingivitis or stomatitis, Vincent's disease is immediately called to mind.In the case just described the physician was undoubtedly misled by the presenceof a false membrane. Probably when-a smear was first made, fusiform bacilliand spirochetes were present, but their presence is not particularly significant,since they are more or less common mouth inhabitants and tend to increase innumber about inflamed areas. The clinical picture was certainly not pathog­nomonic for Vincent's disease, and the lack of quick response to anti-Vincenttreatment should have made one wary. Both smears that I made were entirelydifferent from those found in fusospirillary infections.

Nonspecific Membranous Stomatitis 871

One might be tempted to call the condition a streptococcus stomatitis inview of the large number of these organisms found in the smear and culture,but I do not think that this designation would be correct since other bacteria,such as the staphylococcus, were also found, and the condition might well be dueto a symbiosis of both these microorganisms. Furthermore, anaerobic cultureswere not made, which might have shown still other types. For this reason theterm nonspecific membranous stomatitis seems best.

Laryngologists have described membranous pharyngitis of nonspecific ori­gin. 'Pilley," in his Diseases of the Nose and Throat, has a small section on mem­branous pharyngitis (nondiphtheritic). He attributes this condition to (1)trauma, (2) microorganisms, and (3) complication of certain acute fevers. Themicroorganisms that he considers possible offenders are the staphylococcus,streptococcus, pneumococcus, Bacillus coli communis, and the Friedliinder bacil­lus. No mention is made of the lesion spreading to the mouth.

Hiller, in the article already mentioned, gives a description similar to thecondition of my patient. He says, "The membrane itself is a false mem­brane, moderately thin, white and opalescent and always sharply demarcated,its edges being surrounded by a thin band of hyperemia. It lifts very easily,but is followed by very free hemorrhage from the whole of the bared surfaceand it soon re-forms." While his cases all affected the throat, he makes distinctmention of the spread of the disease to the gingivolabial fold which was so char­acteristic of my case. His cultures yielded also large quantities of Streptococcusviridans and a few of Staphylococcus aureus. The brilliant green in his for­mula, when used alone in aqueous solution, proved to be very efficient-actingquite like a specific remedy.

SUMMARY

A case of membranous stomatitis is described. Smears made from the lesionshowed a preponderance of streptococci, and cultures yielded chiefly Strepto­coccus viridans and a few colonies of Stnp}tylococcus aureus. The condition hadbeen wrongly diagnosed as trench mouth, and treatment directed toward thecure of this condition was of no value. An aqueous solution of brilliant greenproduced a rapid cure.

REFERENCES

1. Hiller, B.:2. Tilley, H.:

A Membranous Oropharyngitis, M.•J. Australia, November !J, 1!J35.Diseases of the Nose and Throat, New York, ed. 4, 1919, Paul B. Hoeber.