Intraoral Herpes Simplex

Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo 

Dental and hygiene students should take note of these images, since lesions like this are often overlooked, or misdiagnosed.  Herpes simplex lesions often erupt on intraoral tissues and, in their mildest manifestations tend to look like this.  They often look larger with large eroded centers and wider white margins.  Note also that they always appear on attached tissue such as the attached gingiva, the hard palate and the dorsal surface of the tongue.

Contrast this to Aphthous (canker sores) which occur exclusively on unattached tissue such as the buccal mucosa, vestibule, soft palate, the ventral surface of the tongue and floor of the mouth.

 

Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

Whenever lesions like this occur in the oral cavity, the patient generally has flu-like symptoms such as headache, fever, malaise and overall body aches.  Asking the patient if he or she has these symptoms may help to confirm the diagnosis.

Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

The image above shows a case of herpes simplex when it involves the tongue.  Note that it occurs only on the ventral (top) surface, and it causes red, swollen fungiform papillae (taste buds).  Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

 

The image above, as well as the three below all came from the same patient.  This series demonstrates a severe primary herpes stomatitis in an 18 year old male.  Note the crusting at the vermillion border on both upper and lower lips, as well as the crusting herpes blister on the upper right lip.  Also note the extremely red and swollen gingiva in all three images.  

The swollen, red gingiva is apparent in these images.  The white "slough" on what appears to be the attached gingiva is an easily removed layer of dead epithelial cells.  In normal circumstances, this layer would be brushed away, or rubbed away by the normal activity of the lips, however this condition is so painful that the patient avoids traumatizing the tissue, even with the normal pressure applied by the lips on the gingiva.  When a clinician first sees a condition like this, his first thought might be that the patient has acute necrotizing gingivitis (ANUG).  At first glance, it is not easy to tell the difference.  ANUG is a bacterial infection, and it is always associated with a strong fetid odor, as well as a white slough directly associated with the interdental papillae.  It the case presented here, the white slough overlies only the attached gingiva, and is not in direct contact with the teeth themselves, and there was no strong feted odor.  Careful observation reveals involvement of the lips and also whitlows (herpes blisters) on the fingers.  The patient has also been suffering from flu-like symptoms, including muscle aches, malaise, nausea and chills, as well as nighttime sweating.  ANUG is localized to the gingiva and does not affect the tongue, lips or skin on the face.  It does not cause the flu-like symptoms presented by this patient, and is not associated with whitlows on on other parts of the body.

For more basic information on the various forms herpes simplex takes, visit HerpesEductaion.Org.