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Oral pathology case: An extreme case of oral herpes

April 15, 2021
A patient with a long and varied medical history presents for an extraction. Dr. Stacey Gividen discovers numerous lesions and gives her diagnosis.

A 70-year-old male presents for an extraction of tooth no. 5 due to gingival-level fracture. The patient was seen two weeks prior for a limited exam to assess the break. At that time, he had received his first dose of the COVID-19 vaccination. At this dental visit, he’d had the second round of the vaccine.

Medical history

Over the course of the last year, the patient reported extreme stress, grinding, and subsequent breaking of teeth, of which no. 6 was extracted not nine months earlier. He received an interim partial denture/acrylic flipper to replace missing nos. 6 and 7. His blood pressure had been noted to increase over the last year, to which he had been turned away at one dental visit and advised to see his general practitioner to get his blood pressure lowered before treatment was rendered.

Furthermore, this patient was recently diagnosed with type 2 diabetes. Chronic back and neck injuries, with prescriptions written for pain medications and muscle relaxants, have been his constant companion for numerous years. In addition to these issues, the patient had a history of drug abuse in the 1970s, the extent of which he claims is one of the reasons his overall health is poor.

Clinical examination

When we sat the patient back in the chair for delivery of local anesthetic, numerous large, irregular-bordered ulcerated lesions were noted throughout the
mouth as well as the perioral area (figures 1–3). The lesions appeared crusted over and yellowish in color. Their size ranged from 5 mm to more than 15 mm.

Upon inquiring, the patient stated that since his tooth broke, his tongue perpetually rubbed against the flipper, eventually causing those lesions, as well as others, throughout his mouth. He said the lesions appeared about one week prior. Given the location and duration of the lesions and the patient’s health history, it was clear that the partial was not the genesis for this pathology; stress and poor health were indeed the culprits.

The diagnosis

Canker sores. Fever blisters. Aphthous ulcers. Herpes type 1 (HSV-1). Yes, all of these as they are one in the same lesion.

The cause

Well, the ramifications of COVID-19 once again have reared their ugly head. Stress, grinding, increased blood pressure, nervous habits, poor diet, diagnosis of type 2 diabetes...put all of these into a melting pot of challenges that place strain on the body’s systems, and something has to give. In this particular scenario—due to the size and conglomerated nature of the lesions—the patient had herpetiform/aphthous major ulcers.

Treatment and discussion

Treatment for this patient was a prescription for acyclovir 400 mg, four to five times a day for a week. He was given instructions for care, which were primarily palliative, for the next seven to 10 days. A prescription for topical cream was denied.

This informative, research-based page on aphthous mouth ulcers will give you a quick guide/reference/refresher on HSV-1. While the existence of canker sores has always been part of many of our patients’ lives, recent environmental stressors have played a role in an increased outbreak across the general population. This has created a need for us, as health-care providers, to up our game in prompt diagnosis, treatment, and encouragement of patient overall self-wellness.

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.

About the Author

Stacey L. Gividen, DDS

Stacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Montana. She is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. Dr. Gividen has contributed to DentistryIQPerio-Implant Advisory, and Dental Economics. You may contact her at [email protected].