5-16
his mouth at hourly intervals with this same 1:1 solution. Issue the patient one pint of hydrogen peroxide.
Caution him not to use this treatment for more than 2 days (due to possibility of precipitating a fungal
infection). Place the patient on an adequate soft diet and advise a copious fluid intake. Adequate rest,
food, and fluid are critical. Analgesics can be administered. Have patient return in 24 hours.
- Second to third day: Patient will be much more comfortable. Using a soft toothbrush soaked first in hot
water, clean the patient’s teeth without touching the gingiva. Maintain the hourly hydrogen peroxide
mouthwash regimen and have patient brush with a soft toothbrush soaked in hot water every hour. Have
patient return in 24 hours. - Third to fourth day: Patient is essentially free of pain. Clean patient’s teeth as before. Floss between all
teeth. Discontinue hydrogen peroxide mouthwash regimen. May initiate chlorhexidine (Peridex) rinses
twice daily for the next 4 to 5 days. Have patient brush 3-4 times a day and floss once a day. - After treatment the acute form subsides and the chronic phase ensues. Although clinical symptoms
are minimal, tissue destruction continues until further corrective measures are completed. Definitive
care consists of cleaning and scaling of the teeth, instruction in oral hygiene and, in some cases, re-
contouring the tissues involved in the infection.
NOTES: Unless the patient develops systemic involvement, antibiotic therapy (including lozenges) should not
be instituted. As in other oral disorders, the use of silver nitrate or other caustics is definitely contraindicated.
Any case of gingivitis that does not respond well within 24 to 48 hours should be referred for evaluation for
underlying blood dyscrasias or vitamin deficiencies.
- HERPETIC LESIONS (COLD SORES, FEVER BLISTERS)
Predisposing factors include emotional stress, the common cold and other upper respiratory infections,
gastrointestinal disorders, nutritional deficiencies, food allergies, and traumatic injuries to the oral mucosa.
In females, menstruation and pregnancy often seem to trigger this process. The herpetic lesion is highly
contagious.
Subjective: Symptoms
Intense pain, itching, burning; in children: greater pain, larger affected area, anorexia, dehydration.
Objective: Signs
Small, localized ulcerations (few blisters in mouth) with a bright red, flat or slightly raised border; later, ulcer
covered by white plaque; generalized infections produce large area of fiery red, swollen, and extremely pain-
ful mucosa; children have more extensive and serious oral involvement resulting in anorexia and dehydration.
(see Color Plates Picture 10)
Assessment:
Differential Diagnosis - herpes zoster (shingles), oral syphilis, burns, erythema multiforme (Stevens-
Johnson Syndrome)
Plan:
- Prevent spread of virus to eyes, fingers or other people.
- Treat precipitating factors.
- Antibiotics may prevent secondary infection in severe cases.
- Force fluids to prevent dehydration.
- Do not use topical steroids.
- 5% acyclovir ointment can be applied to infected areas every three hours for the first few days. Topical
anesthetic (20% benzocaine) can also be applied to reduce discomfort. - APHTHOUS ULCERS (CANKER SORES)
Aphthous ulcers are common manifestations of various systemic diseases such as Bechet’s syndrome, HIV,
autoimmune disorders, and Crohn’s disease. They are not contagious or caused by an infectious agent, and will
heal in 1-2 weeks without sequelae. Stress, acidic foods, and chemical sensitivities may trigger an attack.