Ulcers (traumatic and aphthous) and Herpes: Diagnosis and

“The Great Dilemma”
Ulcers (traumatic and
aphthous) and Herpes:
Diagnosis and Treatment
Traumatic Ulcers
• Very common
• Supportive history usually present
• Varying degrees of pain
• Acute or chronic
• Usually short term (10-14 days)
• A non-healing ulcer must be biopsied
Tongue laceration from
“licking an envelope”
Child with tongue “electrical burns”
from placing battery on
tip of the tongue
Traumatic ulcer from
toothbrush injury
The best treatment for traumatic
ulcers
 Information about trauma and pain
 Palliative care (make the patient comfortable with
analgesics and perhaps a topical steroid)
 Remove the source of trauma! Don’t repeat the act
that caused the ulcer (smooth sharp restorations, tell
them to quit biting their cheek, etc.)
 If the ulcer doesn’t completely heal with 2 weeks after
removal of the likely source of trauma, reconsider the
diagnosis or consider a biopsy.
Aphthous Ulcers
• Reportedly affect 50% of population
• Often found at sites of trauma
• Usually acutely painful
• Freely-movable mucosa
• Often 0.5 -1.0 cm in diameter
• Usually 1-3 ulcers
• Respond to topical steroids
Aphthous Ulcers
• Acutely painful
• Supportive history (may be chronic)
• Yellow-gray-tan pseudomembrane
• Inflammatory “halo”
Aphthous Ulcers
• No single causative factor identified
• T-cell mediated immune reaction
• Biopsies indicate pre-dominance of T
lymphocytes
• Suggests antibody-dependent cellular
cytotoxicity
Aphthous Ulcers
• Allergies
• Trauma
• Stress
• Familial (genetic predisposition)
• Nutritional deficiencies
• Hematologic disorders
• Infectious agents (HIV)
Aphthous Ulcers
• Minor variant
• Major variant
• Herpetiform aphthous stomatitis
“Pseudo-Aphthous” Ulcers
• Often require medical consultation
• Inflammatory or autoimmune bowel
disorders
• Cyclic neutropenia
• Nutritional deficiencies
• IgA deficiency
• Immunocompromised/suppressed
• MAGIC and PFAPA syndromes
Steroid Treatment for
Oral Aphthous Ulcers
• Multiple Ulcers
• decadron oral elixir
• Single to Few
• ointment or gel of choice
Rx Decadron (dexamethasone)
elixir 0.5 mg/5 ml
Disp: 8 oz
Sig: Rinse and expectorate with 1
tblspoon exilir 3-4 times per day
Rx Kenalog in orabase
(triamcinalone 0.1% in oral paste)
Disp: 15 gram tube
Sig: apply sparingly to oral ulcer 2-3
times per day
Rx Lidex (fluocinolone) 0.5%
(ointment or gel)
Disp: 15 gram tube
Sig: apply sparingly to oral ulcer
2-3 X per day for 5-7 days
Rx Temovate (clobetosol
propionate) ointment 0.05%
Disp: 15 gram tube
Sig: apply sparingly to oral ulcer 2 x
per day for no more than 2 weeks
Herpes Viruses
 HSV1
 HSV2
 Varicella-zoster virus (HHV-3)
 Epstein-Barr virus (HHV-4)
 Cytomegalovirus (HHV-5)
 HHV 6 and 7
 HSV8 (HHV8, HSKS)
Herpes Simplex Type 1
 Most common of the HHVs
 Causes PHGS, herpes labialis,
facialis, keratoconjunctivitis, nasialis,
gladitorum, herpetic whitlow, herpetic
encephalitis, etc.
 Not always self-limiting
 Serious sequelae may occur
Primary Herpetic Gingivostomatitis
 Varies from mild (few, if any signs/symptoms)
to serious potentially life-threatening disease
 Symptoms

Malaise, fever, anorexia, headache, sore mouth
and throat, difficulty swallowing
 Signs

Fiery red gingiva, erythematous oropharynx,
lymphadenopathy, fever
Herpes labialis
Recurrent Intraoral
Herpes Simplex
(RIOHS)
Recurrent Intraoral
Herpes Simplex (RIOHS)
can be caused by
HSV1 or HSV2
RIOHS
• Appears on tightly-bound, highly
keratinized tissues
• Initial lesion is a vesicle
• Multiple shallow, punctate ulcers
• May coalesce to form larger lesions
• NOT treated with steroids
Recurrent Intraoral Herpes
vs.
Recurrent Aphthous Ulceration
CASE 1
Your patient is a 42 year-old Caucasian
woman who presents for evaluation of a chief
complaint of, “I have these sore spots on the
inside of my mouth. They started about 2 or 3
days ago, and are really starting to bother
me. They seem to be getting bigger and
more painful. I’ve had these things off and
on since I was about 12 or 13 years old. They
last about 10 days before they heal. Nobody
has been able to help me get rid of them.”
Her medical history is non-contributory. She has
had routine dental visits every 6 months.
She does not use tobacco products and rarely
consumes alcohol. No one else in her family-including her husband--has similar lesions.
She says that the lesions appear at any time
during the month and do no appear to be related
to food or stress.
Her vital signs are within normal limits.
The most likely diagnosis that
your dentist will develop is:
A.
B.
C.
D.
Recurrent intraoral herpes simplex
Recurrent aphthous ulcers
Cicatricial pemphigoid (BMMP)
Lichen planus (erosive)
A.
B.
C.
D.
The best treatment plan the
dentist will develop is to:
Prescribe an antiviral medication
Perform an immediate biopsy
Prescribe a steroid rinse
Do the “Turfing movement”:
immediately refer out of the office!
The most likely diagnosis is:
A. Recurrent intraoral herpes
B. Recurrent aphthous ulcers (the
tongue lesions are consistent with
herpetiform aphthous stomatitis)
C. Cicatricial pemphigoid
D. Lichen planus (erosive)
The best treatment plan is to:
A.
B.
C.
D.
Prescribe an antiviral medication
Perform an immediate biopsy
Prescribe a steroid rinse
Perform the “Turfing movement”:
make an immediate referral out of
the office!
CASE 2
Your patient is a 37 year-old man who presents 5
days following a scaling and root planing (“deep
cleaning”) performed on the maxillary left
posterior sextant. He tells you, “My upper gums
are very painful. It started about 2 days ago. I
think the dentist gave me a bad gum infection
during the cleaning. I’ve never had anything like
this before following a dental cleaning. ”
He is divorced and his medical history shows he
has had gonorrhea twice in 10 years.
He is allergic to penicillin and cephalosporins.
Because he has mitral valve prolapse (his M.D.
states he needs Abx consistent with AHA
recommendations) he was given Zithromax 500
mg 1 hour prior to the “cleaning” procedure.
His vital signs are within normal limits with the
exception of a “low grade fever” (99.6 degrees F).
There is mild left submandibular
lymphadenopathy. All detectable nodes are freely
movable and firm (but not bony hard).
What is the dentist’s most likely
working diagnosis?
A. Initial infection with HSV2
B. Recurrent intraoral herpes (HSV1)
C. Contact stomatitis (probable latex
allergy)
D. Acute atrophic candidiasis
What is the dentist’s treatment
plan most likely to be?
A. Immediately perform a culture and sensitivity test,
then following receipt of lab results start the
appropriate antiviral agent
B. Biopsy
C. Rx: Nystatin oral suspension
D. Provide information on recurrent intraoral herpes,
recommend a palliative rinse and consider Valtrex
prior to next invasive dental procedure
What is your working diagnosis?
A. Initial infection with HSV2
B. Recurrent intraoral herpes (HSV1)
C. Contact stomatitis (probable latex
allergy)
D. Acute atrophic candidiasis
What is your treatment plan?
A. Immediately perform a culture and sensitivity
test, then following receipt of lab results start
the appropriate antiviral agent
B. Biopsy
C. Rx: Nystatin oral suspension
D. Provide information on RIOH, recommend a
palliative rinse and consider Valtrex prior to
next invasive dental procedure
Your patient is a 22 year-old Hispanic male who presents with a
chief complaint of, “I feel terrible. My whole mouth hurts and my
throat is so sore that I can hardly swallow. It started 3 days ago
with a bad headache and then I lost my appetite. My glands are
swollen, too. I’ve never had anything like this before and I hope I
never get it again.”
His medical, dental, social and family histories are noncontributory.
His vital signs are: Temp: 101.4 degrees F; Resp: 18, regular
depth and rhythm; Pulse: 82 BPM, regular rhythm; BP: 128/72;
Ht/Wt: 72”/185 lbs., previously stable with the exception of a
reported loss of “a pound or two” in the last 2 days.
Before you perform the extraoral and
intraoral exams, your patient asks, “My
girlfriend says she’s never had anything
like this either. Can she catch this from
me?”
Case 3
You have seen this young
man before!
From the choices below, please choose the best answer
to his expressed concerns regarding his girlfriend:
A. This condition is not contagious. It is most likely related to
poor oral hygiene.
B. This condition is contagious, but an anti-bacterial agent will
make you non-contagious about 48 hours after you begin
taking the drug that I will prescribe.
C. This disease is most likely related to a food intolerance or a
digestive disorder. It is not contagious.
D. This disease is most likely caused by a virus that you have
not been exposed to before now. It is potentially
contagious through exposure to saliva and the fluid in the
small blisters you have in your mouth.
From the choices below, please choose the best answer
to his expressed concerns regarding his girlfriend:
A. This condition is not contagious. It is most likely related to
poor oral hygiene.
B. This condition is contagious, but an anti-bacterial agent will
make you non-contagious about 48 hours after you begin
taking the drug that I will prescribe.
C. This disease is most likely related to a food intolerance or a
digestive disorder. It is not contagious.
D. This disease is most likely caused by a virus that you have
not been exposed to before now. It is potentially
contagious through exposure to saliva and the fluid in the
small blisters you have in your mouth.