40 Oral ulceration
Alan is 8 years old. He has been brought to the surgery by his mother because his mouth is so painful he cannot eat (Fig. 40.1). What could cause this problem? How would you treat it?
Alan has not been well for a couple of weeks. He had a ‘virus’ that resulted in his being put to bed and missing school. Just as he was improving from this his mouth became very sore. He has been unable to eat solid food for 3 days and has been on liquids only. He feels hot and lethargic. His gums bleed when he tries to brush them.
Alan is generally a healthy boy. He has had a couple of courses of antibiotics for ear infections but has had no real illnesses. He has never been in hospital and is not on any tablets or medicines from his doctor.
There are two types of herpes simplex virus: herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2). Classically HSV-1 causes oral disease and HSV-2 causes genital disease. The viruses, however, are very similar and both can cause both oral and genital disease, although there are differences in recurrence rates. Primary exposure to HSV in the mouth causes acute primary herpetic gingivostomatitis (Fig. 40.1). The virus causes a viraemia, fever, malaise and lymphadenopathy. All the surfaces of the mouth including the hard palate and attached gingiva can be involved, initially with a vesicular rash that ulcerates and becomes superinfected. The illness lasts for 10–14 days before resolving spontaneously. Diagnosis is usually made on clinical grounds but can be confirmed by a threefold rise in the convalescent antibody titre over that seen in the acute phase or by direct immunofluorescence of vesicular fluid using specific antisera.
The primary infection may be mild and subclinical in the majority of young children who are exposed to it, though the condition may be severe and debilitating, and in an immunocompromised individual may lead to severe illness and sometimes herpetic hepatitis or encephalitis, which may be fatal in the absence of treatment.
Oral infection arises from direct contact with secretions from an individual who either has a primary or recurrent HSV infection. Direct inoculation of the fingers or skin with virally contaminated secretions or fluid can lead to local infection, e.g. herpetic whitlow of finger.
HSV is a neurogenic virus, and on recovery from the primary infection the virus may become latent within the trigeminal ganglion or basal ganglia of the brain and may subsequently be reactivated to cause a secondary infection. The secondary infection may cause a ‘cold sore’ on the lip or Bell’s palsy.
Alan responded well to rehydration and analgesia such as paracetamol, which is also antipyretic, and an antiseptic mouthwash such as chlorhexidine (Corsodyl) or benzydamine hydrochloride (Difflam). Had Alan not been able to maintain hydration he would have had to be admitted for intravenous fluid therapy. There is no evidence that systemic aciclovir is of any benefit at the relatively late stage of the condition that he presented. If he had been seen within 72 hours of the onset of the infection, aciclovir could have been prescribed, if the clinical severity warranted it. The dose is 200 mg five times daily for 5 days in patients over 2 years of age, and 100 mg five times daily for 2 days in the under 2 year olds. Although aciclovir can shorten the course of the primary infection, there is no evidence that it reduces the incidence of recurrent herpetic lesions.