oprm-web-case-op-st-17

Patient: Young adult.

Chief Complaint:
Patient complains of painful oral ulcers of five days duration. The patient has not noticed blisters. The lesions have occurred five times previously, always in the same location. The lesions resolved in two weeks for each episode.

Medical History:
No abnormalities identified.

Dental History:
An amalgam restoration was placed in a maxillary right tooth one week ago.

Clinical Findings:
Multiple ulcers are present on the right hard palate in the first molar region. The lesions are tender when palpated and are not thickened.

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
This is a vesicular-ulcerated-erythematous lesion.
Key points:
  ~Acute onset of ulcers
  ~History of previous ulcers in same location involving keratinized mucosa
  ~Ulcers resolve in same amount of time each episode
  ~Ulcers are multiple and grouped in a cluster.
Based on the above key points, a diagnosis of recurrent herpes can be made.
More discussion is given below.

Lesions to Exclude from the Differential Diagnosis:
Hereditary
  ~Epidermolysis Bullosa
      *Ulcers of the skin would be present
      *Onset is typically at birth or in early childhood
*Ulcers are continuously forming and do not recur with complete healing in a consistent amount of time
Mycotic and Bacterial Lesions
  ~Mycotic (candidosis)
      *Lesions are not primarily ulcers.
      *Lesions do not heal in a predictable amount of time
Autoimmune Disorders
  ~Onset of ulcers is slower and not as abrupt
  ~Ulcers are more persistent and progressive
  ~Do not recur in the same location with complete healing in a consistent amount of time.
  ~Usually occur bilaterally
Idiopathic Lesions
  ~Aphthous Ulcers
      *Occur on non-keratinized mucosa
  ~The remaining Idiopathic lesions can be excluded because they do not heal in a consistent period of time.  In addition:
      *Erythema multiforme
Ulcers are bilateral and generalized throughout oral cavity
      *Erosive lichen planus
            Ulcers have more gradual  onset
            Lesions are bilateral
      *Erythroplakia
            Lesions do not occur as discrete ulcers which heal and recur
Viral Lesions
  ~Primary herpetic gingivostomatitis
      *Ulcers bilateral and generalized throughout oral mucosa
      *Tender cervical lymphadenopathy and sometimes systemic manifestations
      *Does not recur as primary herpes
  ~Varicella
      *Skin papules, pustules, and itching rash are most prominent
      *If oral ulcers are present, they are more generalized
      *Varicella does not recur as varicella
  ~Herpes Zoster (shingles)
      *Lesions follow the distribution of a sensory nerve and extend to midline
      *Typically do not recur multiple times
  ~Herpangina
      *Vesicles and ulcers are confined to posterior oral cavity
Hand, foot, and mouth disease
      *Skin lesions present       

Lesions to Include in the Differential Diagnosis:
Recurrent Herpes
  ~Definitive diagnosis can be made on basis of history, location, and clinical appearance.

Management:
Educate the patient about the recurrent nature of herpes simplex virus. Antiviral drugs such as acyclovir are probably not helpful because lesions have been present for 5 days.  Since patient has had 5 recurrences it might be useful to write a prescription for systemic acyclovir and have patient begin medication during prodrome phase, if present.

Final Diagnosis:
Recurrent Herpes