Oral Conditions

cold sore (herpes simplex type 1)

COMMON viral infection that can cause painful blisters or ulcers — typically on the outside of the lips

primarily spreads by skin-to-skin contact — HIGHLY CONTAGIOUS

herpes labialis — infection of the mouth area and lips, most commonly caused by HSV-1 (more commonly known as a cold sore) 

cold sores: signs and symptoms

• located around the mouth

• prodomal (initial, subtle) symptoms

  • skin itches, burning, pain, tingling

  • 6-48 hours before

• skin eruption (10-14 day process)

  • blister or vesicle

  • red

  • fluid filled

  • crust over, dry up, itchy, sore (24 hours)

  • skin heals (7-10 days)

cold sore: common trigger factors

• viral infection (eg. common cold) 

• menstruation 

• dental or surgical procedures 

• immunosuppression 

• exposure to prolonged ultraviolet light (sun) 

• physical or emotional stress 

• fatigue 

• extremes in temperature (cold or hot) 

cold sores: differential diagnosis

Impetigo

• starts as a small, red, itchy patch of inflamed skin

• quickly develops into vesicles that rupture and weep

• dries as a brownish-yellow sticky crust

• mouth and nose is usually affected

Angular Cheilitis

• cracking, crusting, or soreness of the corners of the mouth

• commonly caused by fungal infection but can be bacterial

Chickenpox

• viral infection (varicella)

• rarely occurs at the mucocutaneous junction (where skin meets mucous membrane)

Mouth ulcer

• presents on the inside of the lips/mouth

Treatment for Cold Sores: Aciclovir 5% w/w - 1st line

• only licenced for lips and face for adults, elderly & children

• should be initiated as soon as possible after the start of the infection (ideally during prodromal period - 6 to 48 hours) - can be started during the later stages 

• apply 5x a day for at least 4 days — every 4 hours during waking hours 

• can continue for up to 10 days if needed 

• hygiene - wash hands before and after 

• side effects: transient stinging &/or burning, redness, drying of skin

• refer to GP if cold sores recur frequently (lesions are severe, frequent or persistent)

Treatment: Docosanol - Blistex Cold Sore Cream 

• speed up healing / decrease symptoms 

• does not cure / prevent transmission 

• blocks virus from entering the healthy skin cells and growing in number 

• apply thin layer 5x a day for 4-6 days — max: 10 days 

OTHER treatments for cold sores

Products containing zinc, phenol, ammonia:

• relief discomfort

• eg. Blistex relief cream - apply every hour

Products containing local anaesthetic - eg. lidocaine:

• pain reducing 

• eg. Lypsyl cold sore gel - t.d.s. or q.d.s.

Cold sore: General and Non-Drug Advice

Hygiene

• avoid touching or picking cold sores 

• only touch cold sores when applying topical creams 

• wash your hands thoroughly with soap and water before and after touching cold sore 

• dab cream on cold sore rather than rubbing 

• take care if using contact lenses due to risk of transmission 

Avoid triggers 

• reduce exposure/avoid triggers were possible 

• if sunlight is a trigger use sunscreen lip balm (SPF 15 or more) 

Reducing transmission to others and autoinoculation

• avoid kissing/oral sex until cold sore is fully healed 

  • cold sores are caught by direct skin contact with affected area/saliva 

• risk of transmission from asymptomatic shedding is low, with risk highest during “weeping” stage

• avoid sharing items that come into contact with lesions — eg. lip balms/make-up/straws

• avoid sharing topical treatments with other people

• follow hygiene measures to promote healing and reduce transmission 

• defer elective dental treatment until lesion fully healed 

• herpes virus can be dangerous to newborns, therefore patients should not kiss a baby and wash hands before skin contact

Patient Experience of Cold Sores: Five Stages

Prodromal:

• 6-48 hours prior to eruption

• tingling, burning or itching sensation

• usually around lips or nose

Blister formation:

• blisters may be painful or sore

• can present as individual blisters of small clusters close together

• blister are fluid filled and may appear as clear/red

Weeping:

• blisters burst or weep

• leaves an exposed sore

• fluid may be clear or yellowish in color

Crusting:

• following rupture, blister begins to dry and scab-over/crust

Healing:

• scab heals and falls off

• may take 1-3 weeks for skin to fully heal

• usually heals well and does NOT scar (with exception of severe/extensive blistering)

Cold Sores: Transmission, Progression and Recurrence

Transmission:

• HSV is acquired at mucosal surfaces or at breaks in the skin

• virus initially infects and replicates in the epidermis

• initial infection is most commonly asymptomatic

• incubation period of 2-12 days

Progression:

• virus then travels to the sensory dorsal root ganglia proximal to the site of infection

  • site of infection = typically the trigeminal nerve

• virus lies dormant in a latent state

  • can remain in latent state indefinitely or may be re-activated/triggered by factors personal to patient (eg. stress, hormonal changes, sun)

• upon re-activation, the virus travels from sensory ganglia to outer layer of skin

Recurrence:

• re-activations can be asymptomatic but can still result in transmission of the virus

• recurrent presentation will occur in the same area

Cold Sores: When to Refer

• lasts longer than 14 days

• symptoms worsen OR no significant improvement is seen after 5-7 days

  • eg. lesion spreads, new lesions develop, or if persistent fever or difficulty taking fluids  

• located anywhere else 

• widespread or very large

• immunocompromised patients 

• frequently recurs 

• does not present in the classic way 

• common differential diagnosis: eg. impetigo (refer to GP if patient not eligible for Pharmacy First pathway) 

  • pharmacy first pathway = providing consultations and prescription-only medication for seven common conditions without a GP appointment

Mouth ulcers: Causes and Epidemiology

• aphthous ulcers: most common ulcerative condition of the oral mucosa 

• typically appears as round or oval sore/ulcer inside the mouth 

• majority are self-resolving and transient 

• most resolve within a few days with no need for medical or dental intervention 

• if a healthy person develops mouth ulcers repeated without history of trauma, the condition is known as “Recurrent Aphthous Stomatitis” (meaning repeated ulcerous openings) 

Traumatic causes: 

• inadvertent: accidental cheek/tongue biting while talking/chewing, tooth brushing, thermal burn (eg. hot food/drink), chemical/medication

• latrogenic: accidental damage or over-manipulation during medical/dental procedure (eg. by instrument)

• self-inflicted: teeth grinding and chewing the inside of the cheeks and lips is often linked to stress

Smoking cessation: cause unknown

Genetic predisposition:

• positive family history can be found in 40% of people

Nutritional deficiency: 

• iron deficiency - impaired immune function 

  • more common in females

  • other symptoms include tiredness, pallor, shortness of breath

• folate (vitamin B9) and vitamin B12 

• vitamin C - may also present with gingival oedema, secondary bacterial infection in mouth, loose teeth 

Hormonal factors:

• luteal phase of menstrual cycle for some women

Exposure to certain foods:

• AKA “trigger foods”

• eg. chocolate, coffee, peanuts, gluten-containing foods

Anxiety and stress, immune/imflammatory conditions (eg. Crohn’s disease), medication 

Aphthous Ulcers

3 main types: 

• minor ulcers = most common 

• major ulcers = deeper and larger, and have a raised or irregular border 

• herpetiform ulcers = form as multiple (up to 100) pinhead-sized sores 

  • often fuse together to form larger, irregular shaped sores, which are very painful

NOTE: often occurs inside the mouth (eg. cheeks, tongue, under the tongue, gums), and not contagious

• typically heals within 7 to 10 days

Minor aphthous ulcers 

• very common 

• round or ovoid shaped lesions 

• grey/white 

• affect Non-Keratinized Mucosa (more delicate areas) eg. cheeks, tongue, inside lips 

• small (diameter: 2-4mm) and shallow with clearly defined rim

• very painful - may impact eating and drinking

• can occur in groups of up to 6 ulcers at a time 

• usually heal within 7-10 days 

Major aphthous ulcers 

• less common — represents 10-15% of aphthous ulcers

• diameter of approximately 1 cm or longer 

• longer duration: 10 days to 6 weeks or longer (slow healing) 

• significant pain and dysphagia (difficulty swallowing) 

• can occur in groups of up to 6 ulcers

• can occur on any oral site including the tongue 

• often scar and recur frequently 

• more common in immunosuppressed patients (eg. HIV) 

• REFER 

Herpetiform ulcers 

• uncommon 

• present as multiple “pinhead-sized” ulcers which come together to form a larger area of ulceration 

• very painful 

• can involve any oral site including the tongue 

• takes more than 10 days to heal 

• frequent recurrence may make ulceration seem constant 

• more common in females and later age onset 

• REFER

Questions to ask 

• how many ulcers are present? 

  • minor aphthous ulcers - expect single or small number

• where is the ulcer? 

  • minor AU - located in soft areas

• what does it look like? 

  • pinpoint or large indicates REFERRAL

• how long have you had the ulcer for? 

  • minor ulcers = health with 10 days

  • >3 weeks could indicate sinister pathology (eg. cancer) = REFER

• is the ulcer painful? 

  • minor AU = painful

  • painless lesions could indicate other cause (eg. cancerous)

• can you think of anything which might have triggered it (trauma, stress, foods)?

• age of patient? 

  • more common in younger patients (under 40)

  • children under 10 = REFER to rule out other cause

• other symptoms?

  • systemic symptoms?

  • full illness script may help make diagnosis

Differential diagnosis for mouth ulcers: ORAL MALIGNANCY (mouth cancer)

Signs and symptoms of mouth cancer

• mouth ulcer or sore that does not heal in 3 weeks

• areas that may be affected: inside of cheeks, roof of the mouth, lip, gum, tongue

Different symptoms of mouth cancer:

• lump or thickening in mouth or on the lip

• difficulty or pain with chewing, swallowing or speaking

• bleeding or numbness in the mouth

• bad breath (halitosis)

• loose teeth or dentures that do not fit well anymore

• lump in the neck

• red or white patches that do not go away

Main causes:

• smoking or chewing tobacco

• drinking large amounts of alcohol

Differential diagnosis for mouth ulcers: APHTHOUS-LIKE ULCERS

• appearance like recurrent aphthous ulcer in characteristic

• associated with under-lying systemic condition

• may affect other sites such as genitalia or be associated with systemic symptoms

• systemic conditions that present with aphthous-like ulcers include vitamin b12 deficiency, folate deficiency, coeliacs disease, crohn’s, ulcerative colitis, immunodeficiency, epstein-barr virus (glandular fever)

OTHER Differential diagnosis for mouth ulcer

Primary Oral Herpes Simplex:

• may be asymptomatic or present as gingivostomatitis (inflammation of the gums and mucous membranes of the mouth)

Adverse Drug Reactions:

• NSAIDs

• Nicorandil - second-line treatment for angina

• Beta blockers - may be relationship to starting/increasing dose

Chicken Pox:

• associated with skin lesions

Hand Foot and Mouth:

• blister like lesions may also be on hands and feet (common in nursery age children)

when to refer?

• located towards back of mouth

• ulcers caused by major trauma

• multiple ulcers or one big ulcer

• irregular shaped ulcers

• painless ulcers

• children under 10 years

• more than 14 days (3 weeks must refer)

• major

• herpetiform

• left a scar or elsewhere on the body

Mouth Ulcers: Treatments

• gels, pastes, mouthwashes, liquids, pastilles 

• local anaesthetic (eg. lidocaine, benzocaine) 

  • apply when required but check license

  • Anbesol gel - max every 3 hours

  • Iglu gel - approx. hourly

  • Orajel - 4x a day

• local analgesic

  • eg. choline salicylate, salicyclic acid

  • every 3 hours approx. direct to ulcer

  • Bonjela gel - max every 3 hours

• antibacterial

  • eg. chlorhexidine, benzalkonium, benzydamine HCl

  • Corsodyl MW - 10ml rinse BD (2x daily)

  • Iglu pastilles - dissolve one every 2 hours, max 8 a day

• protective base

  • eg. Carmellose (ingredient) - Orabase

Mouth Ulcers: General and Patient Advise

General advice:

• wash hands before and after treatment

• frequent application 

Patient advice:

• avoiding spicy, acidic, and very salty foods or drinks

• use straw to drink to avoid liquids touching ulcers in the front of the mouth

• use soft toothbrush 

• see GP if suspected that medication is the cause of ulcers 

• salt (saline) mouthwashes — may be done as needed and do not swallow