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).
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| A tiny ulcer visible on the tip of the tongue |
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| Ruptured blisters visible on multiple sites on the lips |
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| 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.
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