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SAEM Clinical Images Series: Spicy Gum Leads to Spicy Gums

Posted by Inna Bulaevsky, DO on

A 32-year-old male with a past medical history of asthma presents with a two-day history of cracked lips and progressively worsening oral pain, associated with white discharge, foul smell, and a metallic taste. The patient presented to urgent care and was sent to the Emergency Department (ED) for a sepsis workup. The worsening sores caused him to eat and drink less, including the gum he normally chews. He endorses oral sex with one female partner one week ago. No recent dental work. He recently completed a prednisone course for the same issue. Denies fevers, tooth pain, tongue pain, dysphagia, odynophagia, chest pain, difficulty breathing, abdominal pain, genitourinary discharge or lesions, sick contacts, trismus, facial swelling, or voice changes.

Additional Images

Physical Exam

Vitals: T 102°F; HR 125; BP 114/81; RR 19; SPO2 94%

General: No distress. Alert and oriented.

Skin: Warm and dry, no rash.

Ears: Hearing grossly intact.

Nose: Bilateral nares patent, no bleeding.

Neck: Soft, symmetric, no adenopathy, non-tender.

Extraoral: Ulcerations on upper and lower lips.

Intraoral: 1 small ulcer on tip of the tongue on the right. Inflamed, erythematous and bleeding gingiva and interdental papilla. Uvula midline. Maximal interincisal opening ~ 40 mm. Teeth intact.

Heart: Regular rate and rhythm, no murmur.

Lungs: Clear to auscultation, air entry to bases.

Abdomen: Soft, non-tender, no guarding.

GU: Patient denied symptoms and declined exam.

Laboratory Data

White blood cell (WBC) count: 11.4

pH: 7.386

Lactic Acid: 1.7

Urinalysis (UA): Negative Blood. Culture sent.

STI workup including HSV titers and HIV testing obtained and pending.

Case Question: What is the differential for acute onset of ulcerated and infected gums?

The differential is broad, including ANUG (acute necrotizing ulcerative gingivitis) also known as “trench-mouth” and, more commonly, primary herpes gingivostomatitis and candidal infection. Consideration of periodontitis and dental abscess/pulpitis is necessary. The spectrum of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis is important to include, as well as autoimmune disorders which commonly have mucosal involvement such as systemic lupus erythematosus (SLE), Behcet’s, and Crohn’s disease. Scurvy, although uncommon, can also present with gingival erythema and pain.

Case Question: What are some risk factors that should be considered when trying to narrow the differential for a patient with gum disease?

Consider the presence of a known autoimmune disorder, chronic systemic disease, or an immunocompromised state. History should include new sexual partners, dietary changes, and changes in dental hygiene. We were concerned given this patient’s vital signs on presentation, and alongside a sepsis workup, called dental to the bedside. They immediately asked the patient about the recent use of chewing gum and its flavor, and the patient described a recent preference for cinnamon gum, which he had been using for about 1-2 weeks. The dental consultant came to the diagnosis immediately. A literature search reveals a phenomenon called “cinnamon-contact stomatitis” which is believed to be caused by a delayed T-cell-mediated hypersensitivity reaction. It is characterized by white patches on the mucosa with erythema and erosions on the buccal mucosa and lateral tongue. Treatment consists of discontinuation of the offending agent, and corticosteroids in patients with severe symptoms. Lesions can take up to two weeks to heal, and appropriate follow-up with dental is needed to monitor for resolution.

Case Discussion

Take-Home Points

  • The differential for ulcerated, painful gums is broad, and one must consider any history of systemic disease or an immunocompromised state.
  • Consider cinnamon-contact stomatitis in patients that present with extensive oral ulcerations in the absence of other risk factors.

References

  • Georgakopoulou EA. Cinnamon contact stomatitis. J Dermatol Case Rep. 2010 Nov 19;4(2):28-9. doi: 10.3315/jdcr.2010.1047. PMID: 21886744; PMCID: PMC3157809.
  • Vivas AP, Migliari DA. Cinnamon-induced Oral Mucosal Contact Reaction. Open Dent J. 2015 Jul 31;9:257-9. doi: 10.2174/1874210601509010257. PMID: 26312097; PMCID: PMC4541332.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM .

Author information

Inna Bulaevsky, DO

Resident Physician
SBH Health System

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