CC
An 11-year-old female is accompanied to the pediatric dentist by her mother. The child was home from school the past 3 days with “flu-like” symptoms; she complains of oral soreness that is accentuated by eating or drinking.
Herpes simplex virus (HSV) infections of the oral and perioral tissues are very common with more than 50% of individuals being affected before adulthood. The vast majority of primary childhood HSV infections are asymptomatic. Symptomatic cases are labeled acute herpetic gingivostomatitis and are most commonly diagnosed between 6 months and 5 years of age. Infection before 6 months of age is uncommon because of passive immunity (transplacental transfer of protective maternal antibodies). Primary HSV infection ultimately leads to latent neurotropic virus in nerve ganglia, with a continual risk for viral reactivation and secondary symptomatic infection (herpetic stomatitis or herpes labialis).
HPI
The patient reports acute onset of malaise, neck soreness, headache, and low-grade fever 3.5 days ago. Diffuse oral soreness became more pronounced 1 day later with painful gingiva and multiple small ulcers on her tongue, lips, and cheeks. The patient has not brushed her teeth in 2 days because of a severe burning sensation that accompanied an earlier attempt. The fever has been manageable with acetaminophen. Irritability and decreased oral intake because of discomfort are frequently the initial presenting symptoms in younger patients.
It is important to distinguish between primary and recurrent HSV infection. The symptoms of primary infection are generally more severe and can be associated with malaise, lymphadenopathy, and fever. Primary infection can involve the entire oral cavity, both keratinized mucosa that is attached to bone and unattached or movable mucosa. Recurrent infection is distinctly limited in distribution in immunocompetent individuals. Most commonly, it is limited to the site of primary inoculation (e.g., lip) or adjacent mucosal sites supplied by the same nerve branch. When recurrent infection is limited to the intraoral mucosa alone, it is generally confined to attached palatal mucosa or gingiva.
PMHX/PSHX/medications/allergies/SH/FH
The patient has not been to the dentist in several years. She reports intermittent mild discomfort of her gums over the past several months and occasionally sees small amounts of blood when she brushes her teeth. She does not have any known drug allergies and is not currently taking any medications. She is premenarche. A friend at school who occasionally borrows her lip balm recently had cold sores.
Herpes simplex virus is transmitted via direct contact with infected secretions from the saliva and other bodily fluids. The main risk factor is a known exposure to the virus. HSV type 1 (HSV-1) is the most common virus responsible for oral herpes but also can infect other mucosal sites and skin. Young individuals may become exposed from a caretaker who is shedding reactivated virus. Latent HSV-1 frequently resides in the trigeminal ganglion, and reactivated virus involves the distribution of this nerve. Several studies have demonstrated viral DNA in the saliva of asymptomatic HSV-1 seropositive individuals, with estimates of asymptomatic shedding being present in 2% to 9% of a randomly sampled population. The incubation time from viral exposure to first symptoms ranges from a few days to just more than 1 week.
Examination
General. The patient is moderately anxious but cooperative and is in otherwise good health.
Vital signs. Blood pressure is 110/70 mm Hg, heart rate is 100 bpm, respirations are 18 per minute, and temperature is 38.2°C. (The patient reports it has been 10 hours since the last acetaminophen dosage.)
Maxillofacial. She has palpable cervical lymph nodes (this is commonly seen with acute herpetic gingivostomatitis). The face is symmetrical, with no other obvious signs of infection or edema.
Intraoral. Multiple small shallow ulcerations are noted to bilaterally involve the lips, tongue, and vestibule ( Fig. 41.1 ). The maxillary and mandibular gingiva appear erythematous and enlarged with focal erosions noted near the free gingival margin (see Fig. 41.1 ). Ulcerations of unattached or movable mucosa are well defined and typically measure less than 3 mm in greatest dimension. They are centrally surfaced with a yellow fibrin coating and are surrounded by a thin erythematous halo. The irregular borders of individual ulcers occasionally run into one another or coalesce. The lip lesions are centered on the mucosa but spill over across the vermillion border.
