Free e-book about Herpetic Gingivostomatitis

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Over 90% of primary herpes simplex viral infections are subclinical. Patients may have non-specific symptoms such as cervical lymphadenopathy, malaise and low grade fever, without discrete clinical lesions. Only about five to ten percent of patients initially infected with the herpes simplex virus develop clinical lesions. This is referred to as primary herpetic gingivostomatitis. These patients also have generalized cervical lymphadenopathy, malaise and fever, but in addition, present with multiple discrete superficial ulcers throughout the oral cavity on both mobile mucosa (e.g.. buccal and labial) and mucosa attached to bone (e.g.. gingiva and hard palate). Some patients especially adults will present with generalized gingival erythema, without discrete lesions. Primary herpetic gingivostomatitis has a sudden onset with discomfort ranging from mild to severe.

Most patients acquire their initial infection through direct contact, e.g.. a parent who has an active recurrent lesion kissing a child. In the vast majority of cases, individuals must have an active lesion(s) to transmit the virus. In rare cases, previously infected individuals may shed virus in their saliva and serve as a source of infection without an active lesion(s) present.

Though all the discrete lesions in the oral cavity start out as vesicles, they are rarely seen clinically because they rupture easily during talking and eating. Most lesions are round, discrete areas of ulceration or groups of ulcers approximately 1-3 mm. in diameter occurring on attached or unattached oral mucosa. The symptoms usually last one to two weeks. The diagnosis of primary herpes is most often made on clinical history and presentation. However, cytologic (PAP) smears of intact or recently broken vesicles may demonstrate epithelial giant cells containing intranuclear eosinophilic viral inclusions typical of herpes viral infections

The main differential diagnosis for primary herpetic gingivostomatitis in patients with predominately gingival involvement without or with few discrete lesions is acute necrotizing ulcerative gingivitis (ANUG). Patients with ANUG also present with a sudden onset of a sore mouth. However, ANUG can be differentiated from primary herpes by the fact that in ANUG the interdental papillae are necrotic while in primary herpes, the interdental papillae are intact. In individuals with primary herpes manifesting multiple oral ulcerations, aphthous stomatitis must be considered in the diagnosis. However, primary herpes can be distinguished from aphthous stomatitis by lesion location and history. Aphthous ulcers occur only on mobile or unattached mucosa and there is a history of recurrence. In contrast, primary herpetic lesions occur on both mobile and attached mucosa and there is no history of previous episodes. Most patients with aphthous stomatitis do not have systemic symptoms such as fever.

Symptomatic treatment for primary herpes consists of rinsing with a 50:50 suspension of Benadryl Kaopectate and/or Viscous Lidocaine. The anti-viral drug used most frequently today to shorten the duration and severity of the primary infection is acyclovir (Zovirax®). It is prescribed (400 mg. q.i.d.) for 1-2 weeks.

Complications are unusual. However children can become dehydrated and can transmit the infection to their eye(s) by rubbing. Herpes keratitis if not properly treated can lead to blindness over time.

Latent Phase

After one has been infected with the herpes simplex virus, it remains latent in the body. It makes no difference whether the infection was subclinical or clinical, the virus goes into this latent phase. The usual reservoir for the herpes simplex virus is a nerve ganglion. In the case of oral infections that is the trigeminal ganglion. In some cases, the virus is never reactivated. In other individuals, the virus is reactivated periodically and results in episodes of recurrent herpes simplex infections.