March 4, 2011

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HSV GINGIVOSTOMATITIS

HSV Gingivostomatitis

• Most common manifestation of primary HSV infection children– 13-30%

• Typically HSV-1• Age 6mos – 5yrs– Can occur in adolescents

• Prodromal illness: fever, anorexia, malaise, h/a

HSV Gingivostomatitis

• Transmission: direct contact with infected oral secretions or lesions

• Viral shedding in primary gingivostomatitis: – At least 1wk– Median 3 weeks

• Incubation period– 2days – 2 weeks

• Reactivation through trigeminal ganglion

Complications

• Dehydration (most common)• Herpetic whitlow• Secondary bacterial infection or

bacteremia• Esophagitis• HSV encephalitis• Eczema herpeticum• Lip adhesions

Supportive Care

• Hydration• Pain control• Barrier for lips– Petroleum jelly

• Topical therapies– Magic mouthwash• Various combinations of benadryl, Maalox, Kaopectate,

viscous lidocaine

Treatment

• Oral acyclovir shortens duration of symptoms and viral shedding

• Topical acyclovir not effective• Immunocompromised: IV acyclovir• Prolonged course of disease:– Consider Acyclovir resistance– Use Foscarnet

• Superimposed infection: amoxicillin or clinda

Isolation

• Children in childcare who do not have control of oral secretions should be excluded

• Hospitalized: add contact precautions

ORAL CANDIDIASIS

Oral Candidiasis

• 60% of healthy individuals harbor Candida in oral cavity– Also skin, intestinal, and vaginal area

• C. albicans accounts for 80% oral isolates– Others: C. glabrata, C. tropicalis

• Infants acquire Candida:– Birth– Postnatally (breast feeding)

• Oral candidiasis (thrush)– 2-5% of healthy newborns

Oral Candidiasis: Setup

• Altered host defense– Infants: immaturity of immune system– HIV & Other immune deficiencies– Diabetes mellitus– Antineoplastic or immunosuppressive drugs– Inhaled corticosteroids

Oral Candidiasis: Setup

• Insult to natural oral flora– Frequent or prolonged antibiotics

• Poor oral hygiene may contribute

Oral Candidiasis

• Symptoms– Asymptomatic– Sore and painful mouth– Burning– Dysphagia– Infants may have decreased PO intake

Pseudomembranous candidiasis (thrush)

• White to yellow plaques and erythema of tongue, soft palate, and buccal mucosa

• Plaques may be wiped off– Raw, erythematous mucosa– Differentiate from “milk curd”

• May also see– Angular chelitis– Fissuring or scaling at corners of mouth

Erythematous candidiasis (atrophic candidiasis)

• Denuded lesions: Palate and dorsum of tongue

• Seen with– Corticosteroids– HIV

Diagnosis

• Clinical diagnosis• Can look for pseudohyphae• If immunocompromised, consider:– Aspergillosis– Cryptococcosis– Histoplasmosis– Blastomycosis– Mucormycosis

Treatment

• Usually responds well to topical agents– Nystatin suspension– 4X daily for 2 wks • (2 days beyond resolution of symptoms)

• Refractory cases or immunocompromised– Fluconazole

Refractory cases

• Children >6y/o with persistent or unexplained frequent relapses, consider immunodeficiency (HIV)

• Maternal colonization or infection in breast fed infants

HERPANGINA

Herpangina

• Coxsackie Group A• Age 3-10 years• Sudden onset high fever, sore throat,

dysphagia, lesions of post pharynx– Anterior tonsillar pillars, soft palate– 1-2mm vescicles that ulcerate and enlarge to 4mm – Surrounded by erythematous ring (up to 10mm)– Average of 5 lesions

Herpangina

• Typically self limited• May be associated with aseptic meningitis

HAND-FOOT-MOUTH

Hand-Foot-Mouth

• Enteroviruses (Coxsackie A and B)– Multiple viruses

• Summer months• < Age 5• Typically self-limited– Low-grade fever?

• Possible aseptic meningitis, encephalitis– Enterovirus 71 (more severe CNS symptoms)

Hand-Foot-Mouth

• Scattered vesicles and ulcerative lesions (4-8mm) throughout oropharynx

• More numerous than herpangina

• Rash hands, fingers, feet, buttocks, groin• May involve palms/soles

HIV GINGIVITIS

HIV Gingivitis

• Generalized linear gingival erythema– Brightly inflamed band of marginal gingiva– Painful, bloody, tissue destruction– Enteric strains and yeast

• Treatment:– Debridement and antimicrobials

RIGA-FEDE ULCERATION

Riga-Fede Ulceration

• Ventral surface of tongue in infants• Continual movement of tongue over lower

incisor• Treatment varies– Observation– Smoothing of tooth edge

GEOGRAPHIC TONGUE

Geographic Tongue(Benign Migratory Glossitis)

• Chronic, recurring• Lesions– Pink to red– slightly depressed– Irregular, elevated, white to yellow borders

• Areas of dekeratinization and desquamation of filiform papilla

• Typically asymptomatic• Reassure