The Case of Herpetic Gingivostomatitis

We were called for a consult at the Orthodontics Clinics for a teenage patient who had developed ulceration on her lips and tongue two days following placement of orthodontic bands. No medications were prescribed to the patient and the patient denied taking any medications during this period. The orthodontist was concerned for erythema multiforme because of the lip involvement. 

We asked the patient a few more questions. The lesions were extremely painful, she hadn't eaten anything for almost 4 days. She had a low grade fever. 

A complete oral examination was difficult because the oral mucosa was extremely tender. We were able to identify a couple of ulcers on the tongue, erythema and swelling on anterior gingiva and a few ruptured blisters on the lips. The lips were slightly swollen. The ulcers were really tiny, about 1-2 mms in size. No other lesions were noted on the body. (Apologies for the bad quality of the pictures, the patient was in a lot of pain and was unable to open her mouth fully for better pictures, she was also reluctant in allowing us to touch her lips, resulting in a very limited view).

A tiny ulcer visible on the tip of the tongue

Ruptured blisters visible on multiple sites on the lips

Erythematous, swollen gingiva

Although we could have attempted to perform a cytology on the lip lesions, the patient was already in a lot of pain and not in a mood for letting us intervene in any way. 

We told the patient to get rest, take lots of fluids, consume soft diet and apply topical anesthetic agents for pain relief. It also took us a while to convince her that the infection has nothing to do with her orthodontic treatment. Although she had forced the orthodontist to remove her bands before her consult, she did reluctantly agree to pursue her orthodontic treatment further.

On one week follow-up, the patient's lesions had healed and she was in good health. 

Primary Herpetic Gingivostomatitis:

Herpetic gingivostomatitis is a very common infection caused by the herpes simplex type I virus. The virus spreads through the saliva. Children tend to be more commonly infected because of their habit of putting things in their mouth, somewhere along the way this leads to contact with contaminated saliva and consequently the disease. Unexposed adults can acquire the infection from children. Adult infections tend to be more severe.

The infection is characterized by tiny oral blisters that rupture to form ulcers that are usually 1-2 mms in size. Larger lesions may be encountered but they usually result from multiple small ulcers coalescing. The lesions may involve any oral surface. Involvement of lips is relatively rare, swelling associated with lip involvement is even rarer. 

Once the viral infection has manifested there is very little you can go except for providing supportive care, like we did in this case. If it is diagnosed at an earlier stage, antivirals may be prescribed to limit the course of disease. 

It is important to note that once infected the virus never really leaves your body. It hides away in your nerves and is reactivated in times of stress. Recurrent lesions always appear at the same site, lips being the most common site. Intraoral presentation of recurrent disease is relatively uncommon. The lesions are preceded by a prodrome (itching or tingling) before the appearance of blisters. 

The Case of the Disappearing Salivary Gland Swelling

A 40-year-old female came to the clinic complaining of a swelling that appeared over her parotid region, was slightly painful but resolved over half an hour. She could speed up the process by applying pressure over the gland. She said that when she applied the pressure, the taste in her mouth became somewhat salty. There were no constitutional symptoms. The patient had seen a couple of dentists before coming to us, she had been advised a series of tests including a panoramic film, ultrasound, complete blood picture and fine needle aspiration cytology. Their listed differential diagnosis was pleomorphic adenoma?

When I examined the patient there was no identifiable swelling, both extra and intra-orally. Thick, mucinous saliva was expelled from the salivary gland on initial milking. The saliva on persistent milking was watery. The panoramic film was clear of any obvious pathology, the ultrasound report was suggestive of inflammation in the salivary gland, and the blood work was normal. Since there was no identifiable pathology, the pathologist had refused to perform an FNAC. 

So we concluded that there was some blockage in the salivary gland duct that was preventing the salivary gland duct to drain completely resulting in the swelling. Once the duct was able to drain the saliva, the swelling would disappear. The blockage in the duct was obviously not because of a lith, we would have been able to see that on radiograph. The cause was most likely a mucus plug. 

Conservative management required us to push the mucus plug out by increasing the salivary flow. We recommended compression of the gland at least twice daily and use of sugar-free lemon lozenges multiple times a day. The patient called after 4 days saying that she was symptom free, and wanted to discontinue lemon lozenges because she didn't care much for the taste. We asked her to complete 7 days and then let us know how she's feeling. 

She continues to be symptom-free for about 2 weeks now. Whatever was obstructing the duct was expelled out by the salivary gland stimulation. 

Comments:

Swellings that grow and regress in size over a period of time are usually inflammatory in nature. Pleomorphic adenoma is a benign salivary gland tumor and was not reasonable differential here. Neoplastic growths don't regress, instead they continue to increase in size. 

Also pleomorphic adenoma would be palpable. No palpable growth was identified during the oral examination.