Mouth Infections

Pediatric Mouth Sores

A mouth ulcer (in this case associated with aphthous stomatitis) on the labial mucosa (lining of the lower lip)
https://en.wikipedia.org/wiki/Mouth_ulcer

Herpes Gingivostomatitis  HSV 1 and HSV 2

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.

 Primary infection occurs approx 1 week after contact w/ infected individual.

• may be subclinical
• 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.
  • All 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.
  • May be accompanied by fever, arthralgia, headache, and cervical lymphadenopath
• perioral ulcers may be found in most children a few days after the appearance of the oral lesions.  These perioral lesions help differentiate HSV infections from apthous ulcers, herpangina, and hand, foot and mouth disease

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.

Diagnosis

• Tzanck smear- smear material from vesicle on slide and stain with Geisma or Wright stain.  Will see multinucleated giant cells
• Cell culture- results in 1-3 days
• Direct fluorescent antibody test (DFA)
• Serologic testing
• PCR

Treatment

• Supportive treatment with the use of analgesics, popsicles, avoidance of citrus or spicy foods, and glyoxide rinse for oral hygiene.
• Viscous of lidocaine (Xylocaine) may be applied prior to meals to allow oral intake  Be 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. 
• One-half mixture of Maalox and Diphenylhydramine applied to ulcers may help alleviate symptoms.
• Topical antivirals do not work.
• Use of oral acyclovir- if used within 48-72 hours, may shorten duration of symptoms and shedding.

Complications

• immunocompromised hosts may require acyclovir.
• autoinnoculation may lead to vesicle formation on other mucosal surfaces, in the eyes, and the formation of a herpetic whitlow on fingers.

Herpes labialis of the lower lip. Note the blisters in a group marked by an arrow.
https://en.wikipedia.org/wiki/Herpes_simplex

Herpetic whitlow on finger
https://en.wikipedia.org/wiki/Herpes_simplex

Hand, Foot, and Mouth Disease

• Usually occur in the summer and fall and caused by infections with enteroviruses, Coxsackie A16, the most common.
• Transmission is fecal-oral and less commonly oral-oral.  Virus may be shed for months after infection.
• Common in toddlers and school aged children.
• 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.
• Children are generally less ill appearing than those with Herpes gingivostomatitis.
• 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. 
4. Gray, pinhead 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.
5. The infection is self-limited, symptoms are generally mild, and lesions resolve within 3-5 days.  Decreased PO intake may lead to dehydration.
6. Treatment is supportive and aimed at reducing pain.

Varicella

• 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.

Oral candidiasis in an infant. At very young ages, the immune system is yet to develop fully.
https://en.wikipedia.org/wiki/Oral_candidiasis

Apthous Ulcers

1. Etiology unclear although associated with many underlying conditions.  Not secondary to HSV infections.
2. Stress, hormonal factors, infections, food hypersensitivity, immune irregularities, familial tendency all associated with occurrence
3. Sodium lauryl sulfate found in many toothpastes has been linked to outbreaks.
4. Vitamin and mineral deficiencies may contribute
5. More common in childhood and adolescence
6. Large ulcerations with gray fibrinous exudate on labial, buccal, or lingual mucosa.  Surrounded by red halo.   Heal within 10-14 days
7. Very painful
8. 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.

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.

References

1. Andreae M. How to recognize and manage herpes simplex virus type 1 infectons.  Contemporary Pediatrics February 2004
2. Hudson B., Powell, C. Towards evidence based medicine for paediatricians. Does oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis? Arch Dis Child Febraury 2009.
3. Scully C. Apthous Ulceration.  NEJM July 13. 2006
4. Krol D, abd Keels M. Oral Conditions.  Pediatrics in Review Jan 2007
5. Delaney J., Keels, M. Pediatric oral pathology. Soft tissue and periodontal conditions. Pediatric Clinics of North America October 2000.