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Mouth Diseases

Oral Herpes without Blisters??

03/15/2011

Question:

My situation is a strange one, but Im hoping someone can shed some light on this for me.

Three weeks ago, I noticed some swelling and pain on the left side of my sublingual saliva gland. When I looked in the mirror, it was more red than normal. I didnt think much of it, chalking it up to irritation from my toothbrush or tortilla chips or something. A couple days later, the right side swelled up just the same as the left. This is when I noticed little white spots that looked similar to what you would have on your throat when you have strep. So I started doing salt water rinses. The spots went away, but the swelling and redness remained.

Then two weeks ago, my top lip started to swell up on the left side and I had a bright red splotch on the inside of it that was tender/sore. I also noticed the white spots had come back under my tongue. A few days later, the right side of my top lip started swelling up as well, and last week my bottom lip was a little swollen. So all in all I looked like someone had popped me in the mouth. But I must mention that the swelling is worse in the morning. It goes down significantly during the day. Inside my mouth, the red patch had spread across the top and also down to the bottom lip. Its not as red as it was, but it is definitely still there. And the pain under my tongue is localized to just the left side now, though it is still reddish and swollen, though that swelling is also worse in the morning and much less severe later in the day.

Now, I never presented with any sort of blisters/sores, not inside or outside of my mouth, just the red splotch and those little white spots which never leaked or anything. My gums were slightly swollen and had been very sore and it felt like I had tiny cuts all inside my mouth, so it hurt to brush my teeth. I had to be careful what I ate otherwise the inside of my mouth just stung. And on top of that, I have some pain/pressure in my cheeks, my temples, and by my eyes but dont know if its related to whatever is going on. Because of the swelling, redness and feeling of tiny cuts, which was very reminiscent of a vaginal yeast infection, I decided to take a Diflucan about 5 days ago in the event that it was oral thrush. I figured it couldn`t hurt.

Last Wednesday, at the behest of my mother, I went to the doctor and all she could come up with was oral herpes/cold sores, though she did not do a swab or anything to be conclusive. When I asked her how I could be like this for 2 weeks, especially with worsening symptoms and never have blisters she could not answer me. She ended up prescribing Acyclovir for ten days.

Then on Friday, being unsatisfied with the previous diagnosis, I saw another doctor who told me it looked/sounded more like an infected and possibly blocked sublingual saliva duct. As for the swollen lips, he said it was probably my allergies since I have terrible allergies from time to time. He told me he did not believe it was oral herpes and to stop taking the Acyclovir. He prescribed an antibiotic and sent me on my way.

So my question is could this really be oral herpes even though I do not have any blisters of any kind? I dont see how thats possible, especially since I have not been sexually active for almost a year and have never kissed anyone with the affliction, let alone have not kissed anyone in almost a year. Ive also never had a prior outbreak and if this were a primary outbreak it would be much worse from what Ive been told. I look forward to your feedback because this is driving me nuts. Thank you!!

ps - Im sure it doesn`t matter, but I am 31 years old and have had both chicken pox and mono.

Answer:

I tend to agree with the second doctors diagnosis. You may have a blocked salivary gland and secondary infection as a result of salivary stasis.

The early morning symptoms that recede during the day could be more postural and also related to the fact that during the night salivary flow diminishes significantly.

This would indicate minor blockage more likely than complete blockage of the duct. As the day progresses, the flow increases and may have enough force to relieve pressure build up in the ductal system. Generally, salivary blockage symptoms increase in the afternoon. (Just before evening meal at which time salivary flow is at its peak) You mention that it is the sublingual gland, are you sure it is not the submandibular gland that is swollen? There are two pairs of glands that are located in the mandibular region floor of the mouth. The submandibular gland has a greater likelihood of blockage because of the tortuosity of its ductal system. One diagnostic technique we used to do (other than perform a radiographic technique of sialography, where we inject radiopaque dye into the salivary ductal system and visualize in real time radiographically) is have you suck on a sour hard candy (Regal Sour Lemon to be specific). The sourness stimulates salivary flow and if a blockage is present this will illicit or potentiate pain in the area.

Did they palpate the glands and try to express fluid from them? I would not be surprised that they may have been able to express purulent discharge if this has been going on for three weeks. 
 
Now what is the etiology of your complaint? Good question, it may be a viral infection that has caused swelling and inflammation and decrease of ductal caliber. Based upon the fact that you had “white spots” on the oral mucosa, it could be related to a viral, bacterial or fungal infection. 

You self-medicated with Diflucan for 5 days; the recommended dosage of Diflucan for oropharyngeal candidiasis is 200 mg on the first day, followed by 100 mg once daily. Clinical evidence of oropharyngeal candidiasis generally resolves within several days, but treatment should be continued for at least 2 weeks to decrease the likelihood of relapse. So what you did was increase the likelihood of developing an azole fungal resistance. The salivary gland problem may resolve but if it is a result of sialoliths, (salivary stones) it may require surgical intervention if symptoms persist. So to answer you initial question, it may be a viral infection but probably not the result of HSV.

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Response by:

Richard J Jurevic, DDS, PhD Richard J Jurevic, DDS, PhD
Formerly, Assistant Professor of Biological Sciences
School of Dental Medicine
Case Western Reserve University