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Oral candidiasis (thrush) is usually painful and looks like creamy-white curd-like patches overlying erythematous mucosa Because these white areas are easily rubbed off (eg, by a tongue depressor) unlike leukoplakia or lichen planus only the underlying irregular erythema may be seen Oral candidiasis is commonly encountered among the following patients: (1) those who wear dentures, (2) those who are debilitated, (3) those with diabetes mellitus, (4) those with anemia, (5) those undergoing chemotherapy or local irradiation, and (6) those receiving corticosteroids or broadspectrum antibiotics Angular cheilitis is another manifestation of candidiasis, although it is also seen in nutritional deficiencies The diagnosis is made clinically A wet preparation using potassium hydroxide will reveal spores and may show nonseptate mycelia Biopsy will show intraepithelial pseudomycelia of Candida albicans Candidiasis is often the first manifestation of HIV infection, and HIV testing should be considered in patients with no known predisposing cause for Candida overgrowth The course of candidiasis in known HIV-infected patients correlates with the degree of immune suppression and overall disease progression, heralding the subsequent development of AIDS For these reasons, oral lesions are useful in staging HIV disease and in designing entry criteria and end points for antiretroviral clinical trials The US Department of Health Services Clinical Practice Guideline for Evaluation and Management of Early HIV Infection recommends examination of the oral mucosa with each clinician visit as well as at a dental examination every 6 months Effective antifungal therapy may be achieved with any of the following: fluconazole (100 mg/d for 7 14 days), ketoconazole (200 400 mg with breakfast [requires acidic gastric environment for absorption] for 7 14 days), clotrimazole troches (10 mg dissolved orally five times daily), or nystatin vaginal troches (100,000 units dissolved orally five times daily) or mouth rinses (500,000 units [5 mL of 100,000 units/mL] held in the mouth before swallowing three times daily) Shorter-duration therapy using fluconazole has proved effective In patients with HIV infection, however, longer courses may be needed, and oral itraconazole (200 mg/d) may be indicated in fluconazole-refractory cases Many Candida species in these patients are resistant to first-line azoles and may require newer drugs,.

Inflammation of the tongue with loss of filiform papillae leads to a red, smooth-surfaced tongue (glossitis) Rarely painful, it may be secondary to nutritional deficiencies (eg, niacin, riboflavin, iron, or vitamin E), drug reactions, dehydration, irritants, foods and liquids, and possibly autoimmune reactions or psoriasis If the primary cause cannot be identified and corrected, empiric nutritional replacement therapy may be of value Glossodynia is burning and pain of the tongue; it may occur with or without glossitis It has been associated with diabetes mellitus, drugs (eg, diuretics), tobacco, xerostomia, and candidiasis as well as the listed causes of glossitis Periodontal disease is not apt to be a factor Treating possible underlying causes, changing long-term medications to alternative ones, and smoking cessation may resolve symptoms Glossodynia is benign, and reassurance that there is no infection or tumor is likely to be appreciated Evaluation of psychological status and anxiolytic medications may be considered as well Symptoms that cannot be related to a specific medication or other cause may be neuropathic in origin An empiric trial of gabapentin may be used for symptom control

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Byrd JA et al Glossitis and other tongue disorders Dermatol Clin 2003 Jan;21(1):123 34 [PMID: 12622275] Zakrzewska JM et al Interventions for the treatment of burning mouth syndrome Cochrane Database Syst Rev 2005 Jan 25;(1):CD002779 [PMID: 15674897]

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INTRAORAL ULCERATIVE LESIONS 1 Necrotizing Ulcerative Gingivitis (Trench Mouth, Vincent s Infection)

Necrotizing ulcerative gingivitis, often caused by an infection of both spirochetes and fusiform bacilli, is common in young adults under stress (classically at examination time) Underlying systemic diseases may also predispose to this disorder Clinically, there is painful acute gingival inflammation and necrosis, often with bleeding, halitosis, fever, and cervical lymphadenopathy Warm half-strength peroxide rinses and oral penicillin (250 mg three times daily

for 10 days) may help Dental gingival curettage may prove necessary Necrotizing ulcerative periodontitis is discussed later in this chapter in the section on AIDS

namespace Example_14_9_ _ _ _Dictionaries { public class Tester { static void Main( ) { // Create and initialize a new Dictionary. Dictionary<string, string> dict = new Dictionary<string, string>( ); dict.Add("Alabama", "Montgomery"); dict.Add("Alaska", "Juneau"); dict.Add("Arizona", "Phoenix"); dict.Add("Arkansas", "Little Rock"); dict.Add("California", "Sacramento"); dict.Add("Colorado", "Denver"); dict.Add("Connecticut", "Hartford"); dict.Add("Delaware", "Dover"); dict.Add("Florida", "Tallahassee"); dict.Add("Georgia", "Atlanta"); dict.Add("Hawaii", "Honolulu"); dict.Add("Idaho", "Boise"); dict.Add("Illinois", "Springfield"); dict.Add("Indiana", "Indianapolis"); dict.Add("Iowa", "Des Moines"); dict.Add("Kansas", "Topeka"); dict.Add("Kentucky", "Frankfort"); dict.Add("Louisiana", "Baton Rouge"); dict.Add("Maine", "Augusta"); dict.Add("Maryland", "Annapolis"); dict.Add("Massachusetts", "Boston"); dict.Add("Michigan", "Lansing"); dict.Add("Minnesota", "St. Paul"); dict.Add("Mississippi", "Jackson"); dict.Add("Missouri", "Jefferson City"); dict.Add("Montana", "Helena"); dict.Add("Nebraska", "Lincoln"); dict.Add("Nevada", "Carson City"); dict.Add("New Hampshire", "Concord"); dict.Add("New Jersey", "Trenton"); dict.Add("New Mexico", "Santa Fe"); dict.Add("New York", "Albany"); dict.Add("North Carolina", "Raleigh"); dict.Add("North Dakota", "Bismarck"); dict.Add("Ohio", "Columbus"); dict.Add("Oklahoma", "Oklahoma City"); dict.Add("Oregon", "Salem"); dict.Add("Pennsylvania", "Harrisburg"); dict.Add("Rhode Island", "Providence"); dict.Add("South Carolina", "Columbia"); dict.Add("South Dakota", "Pierre"); dict.Add("Tennessee", "Nashville"); dict.Add("Texas", "Austin");

gina or buccal and lip ulcers in hand-foot-and-mouth disease) are seen more commonly in children under age 6

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