The infant or child who presents with
"sores" in
the mouth is a common pediatric problem.
Herpes
GingivostomatitisHSV 1 and HSV 2
1. Transmission is by direct contact of
lesions or oral
secretions.Most common in 1-3
year olds. Oral manifestations dictated by whether infection is primary
or
recurrent.
-may
be associated w/ prodrome of fever, malaise, and irritability
-Oral
infection manifested by red, edematous gingiva and clusters of small
vesicles.Presentation may be
abrupt with onset of decreased PO intake, pain, fever, drooling, and
bad
breath.
oAll oral surfaces may be
involved, vesicles
appear over 3-5days
-Vesicles
can coalesce and rupture to form large, painful ulcers of oral and
perioral
tissues.Grayish membrane on a
yellow base.
oMay be accompanied by fever,
arthralgia,
headache, and cervical lymphadenopath
oPerioral 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 and mouth disease
3. Recurrent disease: after primary
infection, HSV migrates
to trigeminal ganglion where it becomes latent.
-Reactivation
may be preceded by exposure to sunlight, cold, trauma, stress, or
immunosuppression
-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.
4. Diagnosis
a.
Tzanck
smear- smear material from vesicle on slide 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
5. 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 intakeBe careful with
young children and should be applied with cotton applicator 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
6. 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.Genital lesions are rare.
5. Children are generally less ill
appearing than those with
Herpes gingivostomatitis.
6. Resolves within 2-3 day without
complication, treatment
is supportive.
Herpangina
1. Principally caused by group A Coxsackie
viruses, but also
by group B Coxsackie viruses and Echoviruses.
2. Greatest incidence in the summer and
early fall 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 exanthem.
3. Gray, pinheahd size vesicles rupture to
form large,
fibrin covered ulcers.Usually on
the anterior tonsilar pillars, posterior pharynx, and soft palate.Average of 5 lesions although some
cases can have up to 16.
-in
addition to fever and oral lesions, headache, vomiting, and abdominal
pain may
occur.
4. The infection is self-limited, symptoms
are generally
mild, and lesions resolve within 3-5 days.Decreased
PO intake may lead to dehydration.
5. Treatment is supportive and aimed at
reducing pain.
Varicella
1. Chickenpox may have vesicles inside the
mouth but the
diffuse skin findings and crusting of vesicles helps differentiate it
from
other infections.
Candida
Albicans
1. Acute pseudomembranous candidiasis, or
thrush, is a
common local infection secondary to overgrowth of the fungus Candida
Albicans.
2. Occurs in children after exposure in
vaginal tract,
children on antibiotics, chemotherapy, radiation, inhaled
glucocorticoids, and
the immunosuppressed.
3. The pseudomembranous form is most
common, and is
characterized by white plaques on buccal mucosa, tongue, palate, and
oropharynx.
-when
wiped, may leave red, raw, and painful surface
4.Also can
present as angular cheilitis or perleche.
5. In HIV (-) patients, treatment consists
of the following:
-Nystatin
swish and swallow
-If
not responsive, oral fluconazole 100-200mg daily
-Recurrence
is common in patients with unmodifiable risk factors.For those with persistent thrush, fluconazole 100mg
daily
can be used prophylactically.
6. In HIV (+) individuals, clinical
presentation can be more
varied and more severe.Thrush is
the most common opportunistic infection in persons with HIV.Treatment is generally more aggressive
to prevent esophageal infection and complications.
Apthous
Ulcers
1. Etiology unclear although associated
with many underlying
conditions.Not secondary to HSV
infections.
-stress,
hormonal factors, infections, food hypersensitivity, immune
irregularities,
familial tendency all associated with occurrence
-Sodium
lauryl sulfate found in many toothpastes has been linked to outbreaks.
-Vitamin
and mineral deficiencies may contribute
-More
common in childhood and adolescence
2. Large ulcerations with gray fibrinous
exudate on labial,
buccal, or lingual mucosa.Surrounded by red halo.Heal within 10-14 days
3. Very painful
4. Treatment is focused on symptomatic
relief
-application
of paste/ointment to ulcers w/ triamcinolone acetonide, fluocinonide,
and
amlexanox.Orabase is one
choice.Early application may
result in expedited healing.
-Correction
of vitamin and mineral deficiencies
-Special
toothpastes w/o sodium lauryl sulfate are available.
Traumatic
lesions and Burns
1.Traumatic
ulcers are the most common oral ulcers in children
-secondary
to mechanical, chemical, or thermal injury.
-Running
and falling with a foreign body in mouth can lead to an "ulcerative"
lesion
2. Lesions generally heal within 2 weeks.
3. Chronic cheek biters and others w/
“self-abusive”
behavior may require more comprehensive management, including bite
guards, lip
bumpers, extraction, and sedation.
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.