Viral and Ulcerative Lesions

Primary Herpetic Gingivostomatitis

Primary herpetic gingivostomatitis is the most frequent acute viral infection of the oral mucosa. Its etiology is the herpes simplex virus type 1 and rarely type 2. Lesions are acquired through direct contact; parent or sibling kissing, sharing of toys.

Vesicles appear on the gingiva, tongue, palate, lips, buccal mucosa, tonsils and posterior pharynx. Perioral lesions may occur occasionally. Vesicles progress to ulcers. The appearance of lesions is accompanied by fever, malaise, and cervical lymphadenopathy.

Occurrence is between 6 months to 6 years but can occur later. The acute phase lasts 7-10 days with spontaneous healing in 1-2 weeks. After healing the virus remains latent in the body.

For patients that can rinse, treatment consists of rinsing with a suspension of diphenhydramine (Benadryl®), Kaopectate and Viscous Lidocaine for topical relief of oral lesions and rest,1 antipyretics, analgesics for systemic symptoms. The clinician should advise the parent of the importance of hydration. Acidic foods (tomato sauce) and fluids (juice) should be avoided. Cold items such as ice cream, popsicles and ice chips can soothe affected tissues. Analgesics, topicals and coating agents may help relieve discomfort. Systemic antivirals may be considered for immunocompromised patients. To prevent further spread of infection direct contact with others should be avoided such as not sharing items such as toys, food, utensils, pacifiers, cups, bottles, toothbrushes and towels.

Image: Primary Herpetic Gingivostomatitis
Image: Primary Herpetic Gingivostomatitis

Recurrent Herpetic Gingivostomatitis

Recurrent herpetic gingivostomatitis is the result of herpes simplex virus reactivation in previously infected individuals. The factors that may precipitate virus activation are: illness, trauma, stress, ultraviolet light and HIV.

It is found on the lips, hard palate and attached gingiva. The symptoms are milder than the primary infection. The oral lesions are a small number of vesicles in clusters that rupture within 24 hours leaving ulcers 1-3mm in size that heal within 6 to 10 days. Lip lesions are covered with a brown crust. Treatment is symptomatic, however systemic acyclovir (200mg every 3 hours while awake for 5 days) may be indicated for children with six or more episodes per year.

Image: Recurrent Herpetic Gingivostomatitis

Aphthous Ulcer/Stomatitis

Aphthous ulcers are painful oral ulcers that tend to recur. The exact etiology is unknown however predisposing factors are trauma, genetics, stress, allergies, hormonal disturbances and AIDS. They tend to appear during the first and second decades predominately in girls.

The severity ranges from minor to major. They are seen on mobile tissues as an ulcer covered by a white membrane surrounded by a red halo. While often mistaken for herpetic gingivostomatitis in appearance, the patient does not develop fever. The ulcers last 6-12 days.

Treatment is palliative; bland diet and application of Orabase® with benzocaine or fluocinonide (Lidex® gel)

Image: Aphthous Ulcer/Stomatitis

Angular Cheilitis

Angular Cheilitis is a common disorder that occurs at the corners of the lips. It tends to appear in the first and second decade with no gender predilection. Its etiology is multifactorial; mechanical irritation, candidiasis, bacterial infection, habitual licking of corners of lips, deficiency anemia, and AIDS. Treatment consists of topical application of antifungal and antibacterial ointment.

Image: Angular Cheilitis


Candidiasis is a fungal infection characterized by raised curdlike plaques that leave raw bleeding surfaces when scraped. It occurs in children who are on long-term antibiotic therapy or are immunosuppressed. It is treated with topical or systemic antifungal agents (Nystatin, clotrimazole).

Image: Candidiasis