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! Dont repeat the act
that caused the ulcer (smooth sharp restorations, tell
them to quit biting their cheek, etc.)
If the ulcer doesnt 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. Ive 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. Ive 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 dentists 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 dentists 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. Ive 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 shes 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.