General oto oral infectious disease

Question 1

What is the natural history of primary herpetic

gingivostomatitis?

Answer 1

Mean duration of:
● Fever: 4.4 ± 2.4 days
● Oral lesions: 12 ± 3.4 days
● Extraoral lesions: 12 ± 3.9 days
● Dysphagia to food: 9.1 ± 3 days
● Dysphagia to liquid: 7.1 ± 2.5 days
● Viral shedding: 7.1 ± 2.5 days

Question 2

What is the most common presentation of a

primary HSV infection in the pediatric population?

Answer 2

Herpetic gingivostomatitis

Question 3

General prodromal symptoms associated with

primary herpetic gingivostomatitis include what?

Answer 3

General malaise, fever, anorexia, irritability, and headache

Question 4

What are primary and secondary clinical findings associated with primary herpetic gingivostomati-
tis?

Answer 4

● Primary: Painful pinhead vesicles that rupture to form
ulcerative lesions, which are irregular and covered by a
yellow gray membrane
● Secondary: Submandibular lymphadenitis, halitosis, and
dehydration from refusal to take in adequate oral
hydration

Question 5

What tests can be used to definitively diagnose an

HSV-1 viral infection?

Answer 5

PCR, viral culture, serology, immunofluorescence.
Note: Tzanck smear is not helpful for delineating HSV-1
from HSV-2.

Question 6

What are potential complications of herpetic

gingivostomatitis?

Answer 6

Dehydration, herpetic whitlow, herpetic keratitis, secondary
bacterial infection, esophagitis, epiglottitis, pneumonitis,
encephalitis, eczema herpeticum

Question 7

What are the three most common antiviral agents
used to treat herpetic gingivostomatitis, and what
is their mechanism of action?

Answer 7

Acyclovir, valacyclovir, famciclovir. Metabolized by viral
enzymes to form metabolites that interfere with DNA
synthesis and cause cell death. It works best if initiated
within 72 hours.

Question 8

What benefit does valacylcovir offer compared
with acyclovir for the treatment of herpetic
gingivostomatitis?

Answer 8

The dosing is twice a day compared with three to five times

per day; however, it is more expensive.

Question 9

What is the generally accepted window of
opportunity for prescribing oral acyclovir for effective treatment of primary herpetic gingivos-
tomatitis?

Answer 9

Three days. This therapy has been shown to decrease the
duration of the lesions (intraoral and extraoral), fever,
dysphagia/odynophagia, and viral shedding.

Question 10

Recurrent oral HSV-1 infections can be associated

with what important complications?

Answer 10

● Disfiguring lesions
● Erythema multiforme
● Aseptic meningitis
● Eczema herpeticum

Question 11

What noncontagious acute gingivitis is caused by an
overgrowth of common bacterial species, including
Prevotella intermedia, α-hemolytic streptococci, Ac-
tinomyces, or spirochetes, among others?

Answer 11

Acute necrotizing ulcerative gingivitis (trench mouth)

Question 12

In a patient with acute necrotizing gingivostoma-
titis, if the disease progresses beyond the gingiva

to include other mucosal surfaces, what is this
condition called?

Answer 12

Noma (cancrum oris)

Question 13

What are common risk factors for development of

acute necrotizing ulcerative gingivitis?

Answer 13

Stress, immune incompetence (i.e., HIV infection), poor
nutrition, poor oral hygiene, alcohol or tobacco use. This is
not a contagious disease.

Question 14

What are common examination findings seen in acute

necrotizing ulcerative gingivitis (“trench mouth”)?

Answer 14

Lymphadenopathy, halitosis, mucosal edema/ulceration/

inflammation, with or without a pseudomembrane

Question 15

What is the treatment for acute necrotizing

ulcerative gingivitis?

Answer 15

● Analgesia (NSAID, narcotics, viscous lidocaine, etc.)
● Antibacterial (clindamycin, penicillin, or erythromycin)
● Oral hygiene (chlorhexidine 0.12% mouth rinse, brushing,
flossing, etc.)
● Dental consultation for debridement and definitive
periodontal therapy
● Management of underlying immunocompromised status
is important if present

Question 16

What is the most common oral manifestation of

HIV infection?

Answer 16

Oral candidiasis

Question 17

What are the common forms of oral candidiasis?

Answer 17

● Pseudomembranous candidiasis (thrush)
● Erythematous (atrophic) candidiasis
● Angular cheilitis (perlèche)
● Hyperplastic candidiasis

Question 18

What in-office diagnostic test can you perform to

confirm the diagnosis of oral candidiasis?

Answer 18

Scraping of erosive lesion followed by potassium hydroxide
(KOH) preparation and looking for budding yeast with or
without pseudohyphae

Question 19

Review the initial treatment options for oral candidiasis.

Answer 19

Topical antifungal lozenges or solutions for 7–14 days:
Clotrimazole troches, nystatin suspension, or nystatin
pastilles

Question 20

What can you offer as treatment for moderate to
severe oral candidiasis or for patients who do not
respond to topical therapy for oral candidiasis?

Answer 20

Oral fluconazole for 7 to 14 days

Question 21

When is daily suppressive management with

antifungals indicated for oral candidiasis?

Answer 21

Suppressive management Is usually unnecessary (even for
HIV-positive patients). Treating active infections and managing the underlying immunocompromised status are recommended. When indicated (usually assisted by Infectious Disease Physicians), management usually includes fluconazole, three times a week.