referred to a dentist for a thorough debridement of the area Failure of response to therapy should trigger an evaluation for underlying immunosuppression FIGURE 117.1 A child with typical “punched out” gingiva—pathognomonic for acute necrotizing ulcerative gingivitis (Courtesy of Dr Mark Snyder.) Primary Herpetic Gingivostomatitis or Herpes Simplex Virus Type Primary herpetic gingivostomatitis, or herpes simplex virus type (HSV-1), is a communicable childhood disease that is not a true dental emergency but is a common cause of ED visits The child is usually an infant or toddler who stops eating, drinking, or talking and is often irritable The child usually has had a fever for to days before any clinical oral findings Older children may complain of headaches, malaise, nausea, regional lymphadenopathy, and/or bleeding gums The physical examination reveals fiery red marginal gingiva with areas of spontaneous hemorrhage Within or days, yellowish, fluid-filled vesicles develop on the mucosa, palate, lips, or tongue The vesicles may coalesce or rupture spontaneously, leaving extremely painful ulcers, covered by a yellow or gray membrane and surrounded by an erythematous zone Ulcers, especially on the lips, may become encrusted, as seen in Figure 117.2 If necessary, a definitive diagnosis can be made by isolation of the herpes simplex virus in tissue culture (although this is rarely indicated) Systemic pain control with acetaminophen or ibuprofen may help facilitate oral intake “Magic mouthwash” (Maalox and Benadryl with or without viscous lidocaine) may be