Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Herpetic Gingivostomatitis
HERPETIC GINGIVOSTOMATITIS
An acute primary herpes simplex infection characterized by painful vesicular lesions and ulcers of the oral mucosa.
I. Etiology: Herpes simplex virus (type 1) in its primary form
II. Incidence
A. Gingivostomatitis is the most frequent manifestation of the primary form of herpes simplex.
B. It is the most common cause of stomatitis in children under 5 years of age, with the highest incidence occurring between 2 and 4 years.
C. It is often contracted from family member with an active HSV oral lesion.
III. Incubation period: 2 to 12 days with a mean of 6 to 7 days
IV. Communicability
A. Highly infectious throughout course of illness, which takes 4 to 5 days to evolve and at least an additional 7 days for resolution
B. Transmitted by saliva and by contact with infected skin or mucous membranes
C. May also be contracted through contact with an asymptomatic carrier
V. Subjective data
A. History of exposure to a child or adult with cold sores or stomatitis
B. Fever: 104F to 105F
C. Irritability
D. Malaise
E. Sore throat and mouth
F. Gums red and swollen
G. Painful sores in the mouth
H. Drooling
I. Foul odor to breath
J. Not eating; taking liquids poorly
VI. Objective data
A. Fever
B. Vesicular lesions:
1. On or around lips, along gingiva, on anterior tongue, and on hard palate; may be seen over entire buccal mucosa
2. Appear on chin and face
3. Vesicles rupture, leaving a grayish ulceration on an erythematous base and may coalesce to form large lesions or ulcers.
C. Gingival edema, erythema, and bleeding
D. Enlarged tender cervical and submandibular glands
E. Increased salivation
F. Foul odor to breath
G. Occasional vesicular lesion on a sucked thumb or finger
H. Rarely may occur as a generalized vesicular eruption
I. May also rarely have herpetic vulvovaginitis from handling genital area with contaminated hands
VII. Assessment
A. Diagnosis is usually made by clinical findings.
B. Differential diagnosis
1. Herpangina: No lesions on buccal mucosa, posterior pharyngeal lesions only
2. Hand-foot-and-mouth disease: Oral lesions not on buccal and gingival mucosa; rash present on hands and feet
3. Varicella: If the rare type of gingivostomatitis with generalized vesicular reaction
VIII. Plan
A. For fever or pain:
1. Acetaminophen, 10 to 15 mg/kg every 4 hours or
2. Ibuprofen 5 to 10 mg/kg every 6 hours
B. One of the following for discomfort:
1. Gly-Oxide Liquid to clean lesions qid (after meals and at bedtime)
2. Viscous Xylocaine:
a. Over 12 years of age: 1 tbsp (15 mL or 300 mg) swished around mouth every 4 hours
b. Children 5 to 12 years: 3⁄4 to 1 tsp every 4 hours
c. Children under 3 years: 1.25 mL applied to affected areas with cotton tipped applicator every 3 hours
3. Chloraseptic mouthwash (for children over 6 years of age): Every 2 hours as needed
C. Oral acyclovir: 15 mg/kg five times a day
1. Marked reduction in viral shedding (1 day instead of 5 days).
2. More rapid resolution of fever, extra oral lesions and problems with eating and drinking.
D. Force fluids: Cold, bland liquids.
E. Tepid baths every 2 hours as needed
F. Tetracycline suspension mouth rinse: 250 mg/60 mL water
1. Cleans and soothes involved mucous membranes.
2. Decreases secondary bacterial infection.
IX. Education
A. Alert parent to signs of dehydration: Decreased urine output, elevated temperature, decreased tears, dry mucous membranes, increased thirst, lethargy (see Appendix H, p. 534)
B. Give cold liquids or semisolids.
1. Try Popsicles, sherbet, ice cream, Jell-O.
2. Maintain hydration with frequent sips.
3. Use straw to minimize contact with lips and gums.
C. Do not give carbonated beverages or citrus juices.
D. Do not be concerned about solid food during acute phase.
E. Do not allow child to swallow Chloraseptic Mouthwash or Viscous Xylocaine.
F. Gly-Oxide: Place 10 drops on tongue and swish around mouth; do not swallow or rinse.
G. Tepid water for baths; air dry or rub briskly to increase skin capillary circulation and heat loss.
H. Dress child lightly.
I. Duration of illness: 1 to 3 weeks
1. Duration of acute phase: 4 to 9 days
2. Ulcers heal spontaneously in 7 to 14 days.
J. Following primary infection, the herpes simplex virus remains latent in sensory neural ganglia, innervating sites originally involved. Therefore, recurrences occur in identical regions but are less severe than primary infections.
K. Recurrent infection appears as a cold sore or fever blister occurring on the mucocutaneous junction.
L. In adolescents, exudative pharyngitis with typical herpetic lesions on the tonsils may be caused by the HSV-2 virus due to oral/genital sex.
M. Careful, thorough handwashing to avoid spread of HSV-1 to other family members and to prevent autoinoculation
N. Note: Highly communicable throughout course of illness. Do not expose to newborns, children with eczema, children on immunosuppressive therapy, or children with burns.
X. Follow-up
A. Recheck in 2 days by telephone.
B. Call immediately if liquid intake decreases or signs of dehydration or secondary bacterial infection appear.
C. Call immediately if complaints of eye problems.
XI. Complications
A. Dehydration
B. Keratitis
C. Conjunctivitis
D. Herpetic whitlow
XII. Consultation/referral
A. Newborns and infants
B. Dehydration in child of any age
C. Generalized skin eruption
D. Signs or symptoms of ocular involvement (photophobia, pain, inflammation, or ulceration of cornea)
E. Immunocompromised child