| MOUTH INFECTIONS AND OTHER COMMON LESIONS
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.
<>References
1. Peter, John. and Haney, Helen Marie. Infections of the Oral
Cavity Pediatric Annals October 1996
2. Andreae M. How
to recognize and manage herpes simplex virus type 1 infectons.
Contemporary Pediatrics February 2004
3. Scully C. Apthous
Ulceration. NEJM July 13. 2006
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