Herpetic gingivostomatitis is primary infection caused by HSV seen in up to 30% of children between 6 months and 5 years of age. Patients usually present with approximately 4 days of fever, malaise, decreased oral intake, cervical adenopathy, and pain in the mouth and throat. Following the prodrome, vesicular and ulcerative lesions appear throughout the oral cavity. The gingiva becomes very friable and inflamed, especially around the alveolar rim. Increased salivation, foul breath, and cervical lymphadenitis may be present. Although fever resolves in 3 to 5 days, children may have difficulty eating for 7 to 14 days. Lesions may last for up to 21 days in severe cases. Autoinoculation may produce vesicular lesions on the fingers (herpetic whitlow).
Management and Disposition
Treatment includes pain control, hydration, and consideration of oral acyclovir therapy. The pain may be significant and often requires oral narcotic pain medications. Control of the pain will allow the patient to consume fluids and remain well hydrated. Acyclovir has been shown to reduce the duration of pain, gingival swelling, oral lesions, fever, and viral shedding if initiated within the first 72 to 96 hours of illness. Avoidance of citrus juices or spicy food is recommended. Cold clear fluids, popsicles, and ice cream may be useful in small children. Not infrequently, admission for IV hydration is necessary. Topical pain control may be achieved by using mixtures of antihistamine (diphenhydramine elixir) and antacid (1:1) applied to lesions with a cotton swab. Local application of viscous lidocaine should be avoided in children, since patients may develop toxic serum levels due to altered absorption from inflamed oral mucosa leading to seizures or methemoglobinemia.
Herpetic Gingivostomatitis. Multiple oral vesicular lesions and tongue ulcerations consistent with herpes gingivostomatitis. Vesicular lesions from autoinoculation are present on the finger (herpetic whitlow). (Photo contributor: Michael J. Nowicki, MD.)
Most lesions are in the anterior two-thirds of the oral cavity. Posterior lesions sparing the gingiva are most commonly seen in coxsackievirus infections.
Primary HSV infection in childhood is usually asymptomatic.
After primary oral infection, HSV remains latent in the trigeminal ganglion until reactivation as herpes labialis.
Herpetic Stomatitis. Multiple perioral vesicular lesions consistent with herpes gingivostomatitis. (Photo contributor: Lawrence B. Stack, MD.)
Herpetic Gingivostomatitis. Multiple oral vesicular lesions and tongue ulcerations consistent with herpes gingivostomatitis. (Photo contributor: Scott Pangonis, MD.)