The infant or child who presents with "sores" in the mouth is a common pediatric problem..

Herpes Gingivostomatitis  HSV 1 and HSV 2
1. Transmission is by direct  contact of lesions or oral secretions.  Most common 1-3 year olds.
2. Primary infection is characterized by a prodrome of fever, malaise, and irritability followed by the appearance of vesicles on a red mucosal surface. 
2. The presentation may be abrupt with onset of decreased PO intake, pain, fever, drooling, and bad breath.
3. The vesicles rupture leaving painful ulcers with a grayish membrane on a yellow base. 
4. All oral surfaces may be involved and vesicles appear over 3-5 days.
5. Perioral ulcers may be found in most children a few days after the appearnace of the oral lesions.  These perioral lesions help differentiate HSV infections from apthous ulcers, herpangina, and hand,foot mouth disease
6. Recurrent disease may have the onset over a period of days with prodrome of itching, burning, or mild discomfort. The ulcers are much less painful  than the primary disease and most often found on the lips.
7. Diagnosis
    a. Tzanck smear- smear material from vesicle on slikde and stain with Geisma or Wright stain.  Will see multinucleated giant cells
    b. Cell culture- results in 1-3 days
    c. Direct fluorescent antibody test (DFA)
    d. Serologic testing
    e. PCR
8. Treatment
     a. Supportive treatment with the use of analgesics, popsicles, avoidance of citrus or spicy foods, and glyoxide rinse for oral hygiene.
     b. Viscous of lidocaine (Xylocaine) may be applied prior to meals to allow oral intake  Be careful with young children and should be applied with cotton applictor 3-4 times /day only.  Give instructions to parents to not give large amounts. 
     c. One-half mixture of Maalox and Diphenylhydramine applied to ulcers may help alleviate symptoms
     d. Topical antivirals do not work
     e. Use of oral acyclovir- if used within 48-72 hours, may shorten duration of symptoms and shedding
9. Complications
     a. immunocompromised hosts may require acyclovir
     b. autoinnoculation may lead to vesicle formation on other mucosal surfaces, in the eyes, and the formation of a herpetic whitlow on fingers. 

Hand, Foot, and Mouth Disease
1. Usually occur in the summer and fall and caused by infections with enteroviruses, Coxsackie A16, the most common..
2. Transmission is fecal-oral and less commonly oral-oral.  Virus may be shed for months after infection.
3. Common in toddlers and school aged children.
4. 1-2 days of fever and sore throat followed by outbreak of vesicles on the buccal mucosa and tongue.  The lesion are slightly painful.  Vesicles are also found on the palms, soles, extremities, and buttocks area.  The rash will improve in about a week. 
5. Children are generally less ill appearing than those with Herpes gingivostomatitis. 

Herpangina
1. Group A and B Coxsackie viruses and Echoviruses.
2. Greatest incidence in the summer in  3-10 year old age group 
3. Prodrome of fever, sore throat, and dysphagia may precede by 1-2 days the development of the enanthem. 
3. Lesions start as macules and progress to vesicles that eventually ulcerate.  Usually on the anterior tonsilar pillars, posterior pharynx, and soft palate.  Average of 5 lesions although some cases can have up to 16
4. The infection is self limited although decreased PO intake may lead to dehydration.
5. Treatment
     a. Analgesics.

Varicella
1. Chickenpox may have vesicles inside the mouth but the diffuse skin findings and crusting of vesicles helps differentiate it from other infections.

Apthous Ulcers
1. Etiology unclear although associated with many underlying conditions.  Not secondary to HSV infections.
2. Large ulcerations with gray fibrinous exudate on labial, buccal, or lingual mucosa.  Surrounded by red halo.
3. Very painful

Traumatic lesions
1. Running and falling with a foreign body in mouth can lead to an "ulcerative" lesion
2. Chronic cheek biters

Burns-
1. Acids, alkali, other toxins

Neutrophile Defects
1. Agranulocytosis
2. Cyclic neutropenia
3. Chemotherapy

Bechet’s 
1. Recurrent ulcers in the mouth and genital areas, fevers, and ocular inflammation.
2. Ulcers in the mouth are painful.
3. Associated with arthritis, inflammatory bowel disease, CNS abnormalities, and skin manifestations.