Incidence : Children 2-10 years old
Infection is unexpected below 6 months
of age due to presence of maternal
antibodies gained by the enfant during
Fever, headache, malaise, lymphadenitis,
nausea and vomiting. These precede the
appearance of oral vesicles by 1-2 days.
The early lesions: vesicles 2-3 mm in
diameter. Rupture of vesicles leaves circular,
sharply defined, shallow ulcers with yellowish
or grayish floors and red margins. The ulcers
are painful and may interfere with eating.
The gingival margins: are frequently
swollen and red, particularly in children.
Sometimes labial and facial lesions
appear without intraoral involvement.
Oral lesions usually resolve within a
week to ten days (Self-limiting).
History of prodromal symptoms 1-2 days
before oral lesions
Negative history of recurrent herpes
Positive history of contact with a patient
with primary or recurrent lesions.
2-The clinical picture
A smear showing virus-damaged cells
A rising titre of antibodies reaching a peak
after 2-3 weeks provides absolute but
retrospective confirmation of the
Supportive measures sometimes are all that is
Acyclovir is a potent antiherpetic drug. It inhibits
DNA replication in HSV-infected cells but has no
effect on normal cells.
Dose: adult: 200 mg 5 times/day (5 days)
Children: 100 mg 5 times /day (5 days)
Recurrent Herpes Simplex
Due to reactivation of latent virus residing
in cells after a previous primary attack (not
A) Recurrent Herpes Labialis
B) Recurrent Intra oral Herpes
:A) Recurrent Herpes Labialis
or burning sensations
Vesicles form after an
hour or two usually in
clusters along the
junction of the lips but
can extend onto the
The vesicles enlarge, coalesce and weep
After two or three days they rupture and
Finally heal, usually without scarring. The
whole cycle may take up to 10 days.
Secondary bacterial infection may change
the lesions into pustules
:B) Recurrent Intra oral Herpes
Clusters of small
vesicles that break
into ulcers, 1-2
mm in diameter,
appear mainly on
hard palate, …).
Treatment must start as soon as the
premonitory sensations are felt.
Acyclovir cream may be effective if
applied at this time.
Chronic Herpes Simplex
It is a variant of recurrent herpes simplex lesion
occurring in immunocompromised patients
(AIDS, immunosuppressive therapy, leukaemia,
Lesions appear on skin or mucosal surfaces as
an ordinary recurrent herpetic lesion but: remain
for weeks or months and develop into large
ulcers (up to several centimeters in diameter).
Systemically administered acyclovir,
doubling the dose; i.e. 400 mg 5
times/day, till healing takes place.
Both primary and secondary herpetic infections
Herpetic whitlow, which is an infection of fingers
after manipulation of herpetic lesions, is a hazard
to dental surgeons and their assistants.
Herpetic whitlows, in turn, can infect patients
In immunodeficient patients such infections can be
dangerous but acyclovir has dramatically improved
the prognosis in such cases .
Mothers applying antiherpetic drugs to children’s
lesions should wear gloves.
:Varicella –Zoster infection
A) Chicken Pox
B) Herpes Zoster
(1) H Zoster of Trigeminal Area
(2) Ramsay Hunt Syndrome
:A) Chicken Pox
A childhood disease
Mild systemic symptoms.
that rapidly develop into
Oral vesicles that rapidly
rupture giving ulcers.
:(1)The trigeminal area
Recurrence of VZV infection occurs typically
in the elderly
Pain precedes the rash (prodrome)
Facial rash accompanies the stomatitis
Lesions are localized to one side (absolutely
unilateral), within the distribution of any of the
divisions of the trigeminal nerve
Malaise can be severe
Sometimes pain occurs without rash or
oral lesions, (herpes sine eruption) which
leads to problems in diagnosis.
The varicella zoster virus produces similar
epithelial lesions to those of herpes
simplex, in addition to inflammation of the
related posterior root ganglion.
Sometimes followed by post-herpetic
neuralgia, particularly in the elderly.
Can be life-threatening in
Secondary infection may cause
suppuration and scarring of the skin.
When the ophthalmic division is involved,
blindness due to corneal scarring may
Oral acyclovir (800 mg five times daily, usually for 7
days) as early as possible.
Intravenous acyclovir :In immunodeficient patients.
The addition of prednisolone (corticosteroids) may
accelerate relief of pain and healing and prevent postherpetic neuralgia in elderly patients.
Corticosteroids or ACTH are given in
addition to antiviral drugs (acyclovir) to
avoid permanent fibrosis of the facial
Common mild viral infection
Causes minor epidemics among school
Characterized by ulceration of the mouth
and a vesicular rash on the extremities.
Caused by strains of Coxsackie A virus.
The incubation period is 3-10 days.
Small scattered oral ulcers usually with little
Intact vesicles are rarely seen
Gingivitis is not a feature.
Regional lymph nodes are not usually enlarged
and systemic upset is mild or absent.
The skin rash consists of vesicles, sometimes
deep-seated, or occasionally bullae, mainly seen
around the base of fingers or toes, but any part
of the limbs may be affected.
Ulcer on the mid-dorsum or tip of the
tongue; the lip or other parts of the
mouth are infrequently affected.
The ulcer is typically angular with overhanging edges and a pale floor, but can
be ragged and irregular.
Ulcer is painless in its early stages
regional lymph nodes are usually
Typical tuberculous granulomas are seen
in the floor of the ulcers.
Chest radiography .
Specimen of sputum. Mycobacterial
infection is confirmed by culture or PCR.
Oral lesions clear up rapidly if vigorous
multi-drug chemotherapy is given for the
pulmonary infection. No local treatment is
An oral chancre appears 3-4 weeks after infection on the
lip, tip of the tongue or rarely, other oral sites.
It consists initially of a firm nodule about a centimeter
across. The surface breaks down after a few days, leaving
a rounded ulcer with raised indurated edges.
A chancre is typically painless but regional lymph nodes
are enlarged, rubbery and discrete.
Serological reactions are negative at first.
Treponema pallidum can be demonstrated by darkground illumination of a smear from the chancre.
Oral chancres are highly infective.
After eight or nine weeks the chancre heals, often without
Develops 1-4 months after infection.
Mild fever with malaise, headache, sore throat and
generalized lymphadenopathy, soon followed by a rash
The rash consists of asymptomatic pinkish (coppery)
macules, symmetrically distributed and starting on the
trunk. It may last for a few hours or weeks
Oral lesions, which rarely appear without the rash, mainly
affect the tonsils, lateral borders of the tongue and lips.
They are usually flat ulcers covered by grayish membrane
and may be irregularly linear (snail track ulcers) or
coalesce to form well-defined rounded areas (mucous
Discharge from the ulcers contains many spirochaetes
and saliva is highly infective.
Serological reactions are positive and diagnostic at this
Develops in many patients about three or more
years after infection.
A characteristic lesion is the gumma.
Clinically, a gumma, which may affect the
palate, tongue or tonsils can vary from one to
several inches in diameter.
It begins as a swelling, sometimes with a
yellowish centre which undergoes necrosis,
leaving a painless deep ulcer. The ulcer is
rounded, with soft, punched-out edges. The floor
is depressed and pale.
It eventually heals with severe scarring which
may distort the soft palate or tongue, perforate
the hard palate or destroy the uvula.
Lesions are confined to oral mucosa ( no
Prodrome: burning sensation (2-48
hours) with the appearance of localized
Ulceration: single or multiple ulcers
appear within few hours. Ulcers are
surrounded by erythema and painful. No
tissue tags surround the ulcers.
Healing: in minor form it takes 7-14 days,
in major ulcers it may take several
months. No scar formation occurs except
in major form.
Healing is characterized by
disappearance of the surrounding
Diagnosis and Management
Check-list for Diagnosis of Recurrent
In cases with underlying systemic
disease : remedy the cause
For minor aphthae: treatment is related
to the severity.
In mild cases:
Protective topical treatment as orabase
Benzydamine hydrochloride mouth wash.
In more severe cases:
Potent topical steroid asTriamcinolone
Treatment of major aphthae.
Effective treatments include
Systemic or intralesional steroids,
Tetracycline mouth rinses. For
herpetiform aphthae particularly .
Chlorhexidine. A 0.2% solution has also
been used as a mouth rinse for aphthae.
Behcet's syndrome was originally defined
as a triad of oral aphthae, genital
ulceration and uveitis. However, it is a
multisystem disorder with varied
Patients are usually young adult males
between 20 and 40 years old.
Patients suffer one of four patterns of disease:
Mucocutaneous (oral and genital ulceration)
Arthritic (joint involvement with or without
Neurological (with or without other features)
Ocular (with or without other features).
The oral aphthae of Behcet's disease are not
distinguishable from common aphthae. They are
the most consistently found feature and
frequently the first manifestation.
The test is positive if there is an
exaggerated response to a sterile needle
puncture of the skin, where such puncture
is followed by pustule formation.
Diagnostic criteria for Behcet's
Recurrent oral aphthae
Eye lesions (uveitis, retinal vasculitiz )
Skin lesions(Erythema nodosum, subcutaneous
thrombophlebitis, hyperirritability of the skin +ve
Arthralgia or arthritis
Vascular lesions (mainly thrombotic)
Central nervous system involvement
No specific treatment, but oral lesions can be
Topical or intralesional corticosteroids
Topical anaesthesia to alleviate pain
Systemic corticosteroids in resistant cases
(40-60 mg prednisone/day).
Combination of steroid and immunosuppressive
drugs (e.g. azathioprine).
A triad of urethritis, arthritis and conjunctivitis.
Painless circinate white lesions that may
ulcerate giving aphthous-like ulcers.
Geographic tongue like lesions
Purpuric rash in palate
This is an acute inflammatory
mucocutaneous disease but among dental
patients oral lesions are the most
prominent or the only ones present
Infections, particularly herpetic can be
Drugs, particularly sulphonamides and
In most patients no precipitating cause
can be found.
The histological appearance
Intraepithelial or subepithelial vesicle or
bulla formation due to widespread
necrosis of keratinocytes
Infiltration by inflammatory cells which
also involve the corium and may have a
Erythema Multiforme Major-Stevens
Erythema Multiforme Minor
Typical cases show at least some target (or iris)
lesions. A typical target lesion is less than 3 cm
in diameter, rounded, and has three zones: a
central area of dusky erythema or purpura, a
middlepaler zone of oedema and an outer ring of
erythema with a well-defined edge.
Atypical target lesions have only two of the
The kobner phenomenon
Localized vesiculobullous form
This form is intermediate in severity. The
skin lesions present as erythematous
macules or plaques, often with a central
bulla and a marginal ring of vesicles.
Mucous membranes are quite often
The onset is usually sudden
There may be a prodromal systemic
illness of 1-13 days before the eruption
Numerous organs are affected, changes
were found with the following frequency:
mouth 100% eyes, skin, male genitalia,
anal mucous membrane, bronchitis and
Antibiotics are usually also given in severe
Pemphigus is an uncommon autoimmune
disease causing vesicles or bullae on skin
and mucous membranes. It is usually fatal
Females aged 40-60 years are predominantly affected.
Lesions often first appear in the mouth but spread widely
on the skin.
Vesicles are fragile . Residual erosions often have
ragged edges and are superficial, painful and tender.
Positive Nikolsky's sign.
Oral lesions show lack of inflammatory signs unless
secondary infection occurs.
Extension of lesions to the vermilion border may lead to
the formation of a crusted lesion.
Intra epithelial vesicles and bullae are
formed. Lesions result from the
destruction of desmosomal junction
between prickle cells and basal cells due
to the presence of autoantibodies against
desmoglein 3 which is an attachment
molecule in desmosomes.
Diagnosis is confirmed by direct
immunofluorescence and by the demonstration
of circulating autoantibodies.
60-100 mg/day of predisolone alone or in
addition to azathioprine (1-1.5 mg/kg daily).
Azathioprine is given to allow doses of the
conrticosteroid to be lowered and reduce their
side-effects. Intralesional steroid application may
Mucous Membrane (Cicatricial)
Mucous membrane pemphiogoid is an
uncommon chronic disease causing bullae and
Skin involvement is uncommon and often trivial.
In stead, mucous membranes all over the body
are affected. The term cicatricial pemphigoid is
sometimes used for this group of disease, but
particularly applies to ocular involvement where
scarring is prominent and impairs sight.
The term desquamative gingivitis is a
clinical description, not a diagnosis. It is
used for conditions in which the gingivae
appear red or raw. Usually the whole of
the attached gingival of varying numbers
of teeth is affected
:Oral Reactions to Drugs
Many drugs can occasionally cause oral
reactions. They are varied in type but
frequently lichenoid or ulcerative. The
mechanisms of reactions to drugs are